Policies and products of Health Insurance.

1. Types of policies
Health care insurance

2. Health Insurance products
General Insurance
companies
pure health
insurance products
individual /
family floater
plans
*Hospitalization exps /
Domiciliary exps
*Hospital cash plan - fixed
rate
*Critical illness policy
*Top up or Surplus insurance
particular disease policies
group insurance
Travel
related
products
individuals & family
students
for countries
personal
accident
policies
Life Insurance companies
*
*Indemnity plans
*Critical illness
policies
*Hospitalization
expenses cum
savings plan
*Hospital cash plan
*Particular disease
plan

3. Basic Types of plans
Standard / core Comprehensive
Tailored plan Group plans

4. 1.Health care insurance for individuals
The primary objective for an individual purchasing healthcare
insurance is to secure medical protection for themselves and
their family. The main benefits, for an individual, of having
healthcare insurance are as follows:
• To pay medical treatment expenses in case of
hospitalisation due to disease or accident.
• Healthcare insurance can help to limit the insured’s out-of-
pocket expenses, protect their assets and even safeguard
their future earnings.
• It takes away the worry of having to arrange money for
potentially life-saving medical treatment at the last minute,
giving peace of mind.
• It acts as a remedy against the absence of any risk
protection measures by the Government to bear the cost of
expenses related to healthcare.

5. Benefits for individuals
• The cost of medical expenses is rising and is expected to rise
further in future.
• With cashless hospitalisation, only an identity card is required
for the patient to be admitted. There is no need to pay for the
treatment and then reclaim it later.
• Treatment is available in the network hospitals of the
insurance company, something that is not usually affordable
by the common man.
• Many insurance companies offer a 24-hour helpline which can
be used to arrange an ambulance or to get information about
the nearest hospitals and the best doctors, for example.
• Anyone, however healthy they are today could be caught off-
guard in future by an unexpected illness or injury.
• In case of critical illness the cost of treatment may be very
high and it is not always possible to meet the expenses from
salary and savings.

6. Health Insurance scope
• The health insurer will indemnify the insured
subject to
– Limit of indemnity
– Deductible
– Hospitalization expenses for more than 24 hours
– Day care procedures (List available with each
hospital)
Exclusions
• Any pre existing disease/ s
• Any disease contracted with in 30 days
of date of inception of policy
• First two year exclusions
First Year and Two year exclusions
Cataract
Hernia
Gall Bladder Stone Removal
sinusitis and other related disorders
Hysterectomy for Menorrhagia

7. Scope and Coverage
Benefits
Core Benefits
In patient
Day patient
Out patient
Ancillary Benefits
Maternity
Dental
Optical
Acute Vs Chronic

8. Typical cover under a Health policy
Cover Details
Hospitalisation expenses Room charges (either suite, private or shared), meals and
operation theatre charges, nursing expenses, fees of medical
practitioner, anaesthetist and consultants. Parent
accommodation accompanying a child (usually under 10 or 12).
Medicine, consumables and
diagnostic expenses
Anaesthetic, blood, oxygen, surgical appliances, medicine and
drugs, diagnostic material and X-rays, dialysis, chemotherapy,
radiotherapy, pacemaker, artificial limbs and organs.
Day care treatment technologically advanced treatment that does not require
hospitalisation for 24 hours or more.
Eye Surgery, Lithotripsy (kidney stone removal),Tonsillectomy,
Dental surgery following an accident, Surgery of
Nose/Throat/Ear, Surgery of Urinary System, Chemotherapy,
Radiotherapy, Treatment related to dog bite/snake bite etc.
Outpatient treatment Consultations, medication, laboratory costs, diagnostics and
physiotherapy. (initially outpatient charges were not covered
under mediclaim policies, but now a days almost all the insurers
are covering OP charges with their own conditions and terms )

9. Typical cover under a Health policy
Cover Details
Domiciliary hospitalisation Treatment administered at home, subject to specified conditions.
Pre- and post-hospitalisation Medical expenses for treatment up to 30 days before and up to 60
days after the hospitalisation. (This period may vary form company to
company.)
Cashless treatment Companies offer customers the facility of cashless treatment by
providing them healthcare identity cards to use in a network of
hospitals.
Free look period A 15-day ‘free look’ period is provided. Within this period if the
policyholder is not satisfied with the terms and conditions of the
policy, then they can return the policy. The company will return the
premium after deducting set charges.
Pre-existing conditions May be covered after a stated period of time (varies from company
to company, but is usually between 2–5 years).
Local ambulance service Expenses incurred for ambulance services to the nearest hospital
where emergency healthcare facilities are available.

10. Common Sub-limits under the Health policy (article on sub limits)
Item Limit
Room, boarding and nursing expenses provided
by hospital / nursing home including service
charges.
Up to 1% of sum insured or Rs. 5000 which ever
is lower (per day). If admitted to the intensive
care unit (ICU): up to 2% of sum insured subject
to max of Rs.10,000/- per day.
Surgeon, anaesthetist, medical practitioners,
consultants, specialist fees.
Up to 30% of sum insured per illness/injury.
Anaesthetists, blood, oxygen, operation theatre
charges, surgical appliances medicines/drugs,
diagnostic materials and X-ray, dialysis,
chemotherapy, radiotherapy, cost of artificial
limbs etc .
Up to 40% of sum insured per illness/injury.

11. Common exclusions of a health policy
• Any pre-existing condition (until the waiting period is over).
• Specified illnesses for the first year.
• Specified illnesses in the case of domiciliary hospitalisation.
• Any treatment for the first 30 days from the time of inception
of policy, unless it is due to an accident.
• Treatment related to HIV/AIDS.
• Treatment due to abuse of alcohol or intoxicants.
• Vaccination and boosters
• Nuclear and war perils.
• Naturopathy treatment.
• Experimental or unproven treatment.
• Obesity treatments
• Neurological and psychiatric conditions.

12. Common exclusions of a health policy
…2
• Self-inflicted injuries.
• Self-poisoning.
• Gender reassignment.
• Sleep disorders.
• Speech disorders.
• Dialysis required for chronic renal failure.
• Dental treatment not requiring hospitalisation.
• Infertility treatment
• Treatment arising from, or traceable to, pregnancy and
childbirth, including caesarean.
• Birth control devices or pills.
Contd……..

13. Common exclusions of a health policy
…3
• Treatment that is purely diagnostic in nature with no positive
existence of any disease.
• Treatment of congenital external disease/defects/anomalies.
• Treatment that is mainly cosmetic in nature.
• Spectacles, contact lenses and hearing aids.
• Treatment taken from a person not registered as medical
practitioner.
• Mobility aids, prostheses and corrective devices.
• Organ transplantation
• Injuries arising from hazardous pursuits (such as diving).
• Services or treatment in any home, spa, hydro-clinic,
sanatorium or long-term care facility.
• Vaccinations and medical certificates, including examinations
for employment or travel.

14. Expenses not covered in the policy
• Admission/Registration Charges
• Telephone Charges
• Attendant’s Changes
• Home Visit/Nursing Charge – at residence after discharge
• Assistant fee/Follow up Charges in advance
• Thermometer Charges
• Container for Specimen/Disposable Bag Charges
• Admission Kit
• External Surgical Aids: Lumbo‐Sacral/Collar belt/ Knee cap/Knee
brace/Walker/Hot water bag/Baby kit/Urine pot/Traction kit/Folding
commode etc.
• Inhaler/Nebulizer
• Diet Charges
• Special/Protein diet/Health drinks unless prescribed by the Doctor
• Documentation/Folder/Stationery/In Patient chart Charges
• Surcharge

15. Ancillary Benefits
• Ancillary benefits are outside the scope of basic and
standard plans (and available for additional premium), but
are usually incorporated into comprehensive plans.
1. Maternity
Charges made for pre-natal, childbirth and post-natal
treatment of a female insured. General benefits structure
include:
• Normal delivery: ante-natal and post-natal care.
• Caesarean delivery: ante-natal and post-natal care.
• Legal abortion/miscarriage.

16. Ancillary Benefits/2
• Dental
Dental plans vary enormously in what they cover; a
comprehensive plan might include:
• Diagnostic services, including routine examinations and x-
rays.
• Simple restorative care, including amalgam (silver filling).
• Crowns and jackets.
• Treatment of disease, gum abscesses and root canal
therapy.
• Oral surgery.
• Bridges and dentures.
• Orthodontia.

17. Ancillary Benefits/3
Optical
This refers to vision care and a comprehensive
plan might include:
• Eye examination
• Lenses
• Frames
• Contact lenses

18. 2. Critical illness policies
• In a Critical illness insurance the insurer is
contracted to typically make a lump sum cash
payment if the policyholder is diagnosed with one of
the critical illnesses listed in the insurance policy.
• The policy may also be structured to pay out lump
sum amount or regular income and the payout may
also be on the policyholder undergoing a surgical
procedure, for example, having a heart bypass
operation.

19. Common list of critical illnesses
• Alzheimer’s disease – resulting in permanent symptoms.
• Blindness – permanent and irreversible.
• Cancer – excluding less advanced cases.
• Coma – resulting in permanent symptoms.
• Deafness – permanent and irreversible.
• Heart attack – of specified severity.
• Kidney failure – requiring dialysis.
• Loss of speech – permanent and irreversible.
• Major organ transplant.
• Multiple sclerosis – with persisting symptoms.
• Paralysis of limbs – total and irreversible.
• Parkinson’s disease – resulting in permanent symptoms.
• Stroke – resulting in permanent symptoms.
• Third degree burns – covering 20% of the body’s surface area.
• Traumatic head injury – resulting in permanent symptoms.
With increasing
competition, the scope
of protection offered by
these policies has
steadily extended in
recent years.

20. Survival period and waiting period
• The policy may require the policyholder to survive a
minimum number of days (the survival period) from
when the illness was first diagnosed.
• The survival period used varies from company to
company, however, 28 days and 30 days are the most
common survival periods used.
• In addition to this a 90 – day waiting period is
applicable, i.e, Any illness within 90 days from start
date of policy will not be covered.

22. 3.Travel insurance
Travel insurance is intended to cover medical expenses, travel
related accidents and losess, and other losses incurred while
traveling. ( Domestic as well as Abroad)
Insurance can be purchased for many different types of travel,
including:
• Individual
• Family travel
• Student travel
• Sr Citizen travel and
• International travel
 Available for all ages between 3 months – 70 years and senior
citizens between 71 to 85 years
 Cover trips from as short as 1 day to max of 360 days

23. Typical cover (healthcare) available under a travel insurance policy
Cover Details
Healthcare cover
Emergency medical expenses Medical costs incurred due to illness or accident
including medically necessary and prescribed
emergency evacuation. It covers out-patient, in-
patient, medical aid, therapies and diagnostic tests
as described in the policy schedule.
Repatriation in case of medical
emergency
Expenses involved in repatriation to the insured’s
home country in case of medical emergency.
Repatriation of mortal remains Expenses of repatriating the remains of the insured
back to their home country, in the event of their
death overseas.
Dental expenses Dental emergency expenses following an accident.
Hospital cash Daily allowance payable, as stated in the policy.
Personal accident Compensation paid in case of death or permanent
total disability caused by an accident.

24. Typical cover (non - healthcare) available under a travel insurance policy
Non-healthcare cover
Flight delay
Compensation if the aircraft is delayed for more than
twelve hours beyond the original scheduled
departure time.
Trip cancellation Compensation for loss of personal accommodation
or travel charges following the necessary and
unavoidable cancellation of the trip due to death,
serious injury or sudden sickness of the insured or a
family member.
Loss of passport Expenses incurred in obtaining a replacement for a
lost passport.

25. Typical cover (non - healthcare) available under a travel insurance policy
Non-healthcare cover
Loss of checked-in baggage Compensation for the permanent loss of checked-in
baggage.
Delay of checked-in baggage Compensation for reasonable expenses incurred for
the purchase of toiletries, clothing and medication
due to the delayed arrival of checked-in baggage,
where the delay is for more than twelve hours.
Hijack distress allowance In the event of the hijack of the air or sea common
carrier in which the insured person is travelling
whilst on the trip abroad during the period of
insurance. An allowance will be paid for each day of
the hijack up to the limit specified under the policy.

27. Exclusions of travel insurance
• Self-inflicted injury, suicide.
• Being under the influence of alcohol or drugs.
• Participation in any criminal act.
• AIDS/ HIV.
• Treatment of nervous and mental problems.
• Participation in hazardous pursuits.
• Civil or foreign war
• Pre-existing conditions except in case of life-threatening
situations
• Radiation, nuclear weapons induced Sporting activities
• Expenses arising out of loss of valuables, money, securities
and tickets
• Loss of passport in public place

28. Personal Accident policies
Accidents do happen. In India there is an accidental death
every 2 minutes.
Personal accident insurance covers the risk of bodily injury
arising directly from an accident that was caused by external,
violent and visible means and results in death or disablement.
A term plan can only help in death and a health plan can help
in case a person is hospitalized, some of these policies also
offers accidental riders, but these riders are not as
comprehensive as standalone Personal Accident Insurance
policies have .
The premium of accidental policy does not depend on age .
It would depend on the working conditions and nature of
person’s job

29. Scope and coverage

32. Other features
• Some companies covers claims arising out of
Terrorism or acts of Terrorism
• No health check-up required for policy
issuance
• Worldwide coverage of the policy
• It gives coverage starting from 5 lacs to 50 lacs
• Free lookup period of 15 days
• 5% per claim free year to a maximum of 50%.

33. Exclusions
• Any pre-existing disability, condition or any
complication arising from it; or
• Suicide, attempted suicide or intentionally self-
inflicted injury or illness, mental or nervous
disorders or
• Participation in illegal activity ./ criminal activity;
• AIDS/HIV; and
• Hazardous pursuits.
• Influence of intoxicating liquor or drugs
• Military service or operations

34. Non traditional plans
When doors of privatization opened three things
happened,
1. The concept of ULIP was introduced
2. Traditional agent has suddenly many more
work options and could have move from
company to company
3. New channels of distribution – corporate
agency tie ups

35. Non traditional plans
• A ULIP (Unit Linked Insurance Plan) is a life
insurance policy which provides a
combination of risk cover and investment –
market related .
risk cover
various charges
investment

36. Different charges
• Mortality Charges
These are charges to provide for the cost of insurance
coverage under the plan.
• Premium Allocation Charge
This is a percentage of the premium appropriated towards
charges before allocating the units under the policy.
• Fund Management Fees
These are fees levied for management of the fund(s)
. Policy/ Administration Charges
• Surrender Charges
• Fund Switching Charge
• Service Tax Deductions

37. ULIP products
• ULIP has addressed and overcome several concerns that
customers had about life insurance –
Liquidity
Flexibility
Transparency
• ULIP’s are into
– Retirement /pension planning
– Health plans
– Lots of investment plans
– Children plans
– Marriage and education plans

38. How ULIP concept works?
• The investment is denoted as units and is
represented by the value that it has attained
called as Net Asset Value (NAV).
• The policy value at any time varies according to
the value of the underlying assets at the time.
• The returns in a ULIP depend upon the
performance of the fund in the capital market.
• ULIP investors have the option of investing across
various schemes, i.e, diversified equity funds,
balanced funds, debt funds etc.

40. General Description
Nature of Investments Risk Category
Equity Funds Primarily invested in
company stocks with the
general aim of capital
appreciation
Medium to High
Income, Fixed Interest and
Bond Funds
Invested in corporate
bonds, government
securities and other fixed
income instruments
Medium
Secured Funds Investment in govt
securities, bank deposits
and government securities
Low
Balanced Funds Combining equity
investment with fixed
interest instruments
Medium

42. Health Savings Plans by Life Insurers
• With ULIPs regaining lost popularity, life
insurers have gone one step ahead by
providing Unit Linked Health Care Plans or
Money Back Health Insurance Plans,
combining investments and health insurance.
• The popular plans in this category are ICICI
Prudential's Health Saver, Birla Sunlife's Saral
Health and LIC's Health Protection Plus.

43. Health Savings Plans (HSPs):
• Health Savings Plan offer a blend of an
investment account as well as a health cover.
Under this, a part of the premium is allocated
towards a savings or investment account, while
the rest is utilized towards offering a protective
cover.
• While the exact percentage of allocation towards
savings or investments and health insurance will
vary from company to company, typically a health
savings plan would allocate 30-40% of the
premium for savings.

44. ULIP - Health plans
So far, few Indian life insurers, such as
• LIC – Health plus, health protection plus
• ICICI Pru life
• Reliance Life
• HDFC Life
innovated with health plus savings products.
Health benefits: the LIC’s health protection provides a
fixed ‘per day’ hospital cash benefit where as ICICI Pru
Life has an indemnity based health cover.

45. Specific Disease policies
• Changed requirements of the people to
manage the high costs associated with the
treatment.
• Needs to be offered separately – involves
complexity – different terms and conditions

46. Health plus life - combi product
• Promoted by both life and non-life companies/
stand-alone insurance companies
• Mandatory to have a MOU between the insurers
• Under writing of respective portion should be
carried out by respective companies
• Premium sharing and claims settlement will be
done as per the risk shared by each companies.
• Future Generali, Reliance life are offering such
polices in the market

49. Group Insurance introduction
• Insurance plan for a group of Individuals
• It covers group of people against loss of life,
health or disability
• “Power comes in numbers”
• Type of coverage available all over the world
might vary for different states and different
countries

50. Importance of Group Insurance
• Increasing life span resulting from better
health care
• Increasing prevalence of diseases relating to
our dietary and behavioral habits, known as
life style diseases.
• The rising incidence of such diseases
especially among employees in the organized
sector, make both public sector and private
sector.
• Hence employers look group insurance as an
important employee benefit.

51. • After Life Insurance nationalized and LIC of India
came into life insurance business the importance of
group insurance recognised
• Today all the private life insurance companies are
also having different group insurance plans with
various unique features.
• Among private insurers, ICICI Pru, Bajaj Allianz,
HDFC Standard and Birla Sunlife grabbing good
business in the group insurance category. However,
LIC retained its dominant position with 80% market
share

52. largest group insurance policy

53. LIC vs INFOSYS
• LIC has signed the largest group insurance policy with
Infosys Technologies worth Rs 24,000 crore. The policy
covers 97000 employees of Infosys.
• Depending on the rank the employees are eligible
between Rs 20 -80 lakh in the event of death of the
employee. The cover of Rs 10 lakh has been given in the
policy in the case of accident.
• The Infosys-LIC association is not new and has been in
existence since the year 2002. Earlier in that year LIC
covered just 12,000 employees
• LIC has group insurance deal with Hindustan
Aeronautics (HAL) that covers 52,000 employees. Its
Wipro deal covers 60,000 employees.

54. Group insurance – Fundas
• It is a contract between the Insurer and the
representative of the group who is called
“Master Policy Holder”
• Group policies are normally one year
renewable contracts – hence premium varies
every year due to changes in the group
• Experience rating system
• Group insurance plans may be of two types:
contributory or non contributory.

55. Fundamentals continues …
• “A group should consist of persons who assemble
together with a commonality purpose or engaged in a
common economic activity like employees of a
company.”
• It should be a homogeneous group of persons formed
already.
• No group should be formed with the main purpose of
availing insurance……Guidelines of the regulations
issued by IRDA.
• There must be minimum number of members in the
group.
• Sufficient new members must enter the group
periodically.

56. Types of coverage
Medical
cover
Critical
illness
Accident
cover
Health
insurance
Pension
Cover
Life cover

57. Employees benefits offered by companies
StatutoryVoluntary
Pensions
Leave encashment
Savings policy
Life insurance benefits
Personal accident
benefits
Medical & health insurance
Other perks
Workmen’s Compensation Act
Employees State Insurance Act
EPF
EDLI
EPS
Payment of Bonus Act
Payment of Gratuity Act

58. Employees benefits that are supported by group insurance
StatutoryVoluntary
Pensions
Leave encashment
Savings policy
Life insurance benefits
Personal accident
benefits
Medical & health insurance
Other perks
Workmen’s Compensation Act
Employees State Insurance Act
EPF
EDLI
EPS
Payment of Bonus Act
Payment of Gratuity Act

59. Eligible groups for taking Group Insurance
Employer
-
Employee
Creditor vs
Debtor
Professionals
Others :
rural, urban
weaker
sections
Labor Union

60. •Group policy is taken by the employer for the benefit of
the employees either as a welfare measure (as a model
employer) or to meet as legal liability such as Gratuity
liability, or liability for superannuation benefits.
•Any scheme can be either contributory or non-
contributory.
•Normally no evidence of health of the members joining the
scheme is called for.
Other rules are:
(a) the employee should not be absent from duty on
medical grounds as on the date of commencement of
the Scheme
(b) the employee should not have availed leave on medical
grounds for one week or more during the last six
months or one year as per the practice of the Insurer..
In some schemes all the employees are admitted into the
scheme irrespective of their health condition.
Employer –employee

61. Creditor – Debtor
• The contract owner in these plans is
the creditors, such as bank, a small –
loan company, a credit union.
• If debtor dies or become disable, the
insurance proceeds generally paid to
the creditor to liquidate the
indebtnesss that provided the basis
for coverage rather than to the
individuals who are insured or
beneficiaries.
• Debtors usually must be under a
binding irrevocable obligation to repay
the indebtedness for coverage to be
effected.

62. Professionals
These are homogeneous groups like
Doctors, Lawyers, Engineers, Teachers,
Accountants, Journalists, and
Architects Etc

63. Labor Union Groups
• Members of labor unions may be
covered under a group contract issued
to the union itself.
• It is common, however, for payment to
be made from funds partially
contributed to the union by members
specifically for their insurance and
partially by the union from its own
funds. In some cases the union pays the
total premium from its own funds.

64. Others
• Rural sector : Milk producers, Agriculturists such as cotton growers,
groundnut producers, Handloom weavers, toddy tapers, beedi rollers.
• Urban sector : Fishermen, taxi & auto rickshaw drivers, rickshaw
pullers, tailors, barbers, dhobis, manual labourers such as
constructions workers, quarry workers, etc.
• Other weaker groups : Self employed women, Blind, physically
handicapped, leprosy and other disabled persons, Forest labourers,
transport workers, workers of small industries such as gunny bag
workers, leather workers, etc. Assistants in small shops and
establishments
• RSBY
Health
Insurance
• Janshree
bima
yojana
Life
insurance
• Shiksha
Sahayog
Yojana
Scholarship
• Aam Admi
Bima
Yojana
Land less
house hold

65. Major Differences Between Group and Individual
health Insurance
Benefit Individual Group
Pre check individual health insurance
requires all applicants to
undergo medical
examination before their
policy can be approved.
Group life insurance
provides a guaranteed
amount of coverage which
means no medical
examination is necessary to
qualify for the coverage
pricing Individual health insurance
is rated based on the
applicant sole lifestyle,
medical history, and social
affiliations
Will be rated based on an
experience approach. The
rate you need to pay will
not be predetermined by
your health condition but
the assessment of the
entire group which you
belong to.

66. Major Differences Between Group and Individual
health Insurance/2
Benefit Individual Group
Billing and
Administration
Systems
individual health insurance
is managed solely by the
policy holder
Most insurance companies which provide
group insurance policies hire a particular
administrator who handles the account of a
specific group. The administrator monitors the
payment and benefits claims of each member
of the group.
Scope of
coverage
individual insurance which
requires a reassessment of
entire application fro
inclusion.
The increase in the scope of coverage for
group health insurance is easier. need to
present legal documents if wish to include
wife, child or parents into the policy.
Exclusions Can be covered by paying
an additional premium.
Included some of the exclusions like maternity,
dental, optical, pre existing disease etc

67. Healthcare insurance products
Summary
– Individual and Group Floater Indemnity products
– Critical Illness Benefit products
– Hospitalization Benefit and Surgical Benefit products
– High Deductible and Top-Up covers
– Micro health insurance products
– Overseas travel and International comprehensive
coverage
– Specific disease products- Cancer, HIV, Diabetes, cardiac
etc
– Products for different age groups- Senior Citizens, Women
– Products with outpatient coverage in some form
– Linked and Unlinked Health Savings Products etc.

68. Further ideas …….
• Currently, non-life insurers and stand-alone
insurers are allowed to design and sell
individual products of falling under the short
term category i.e max up to 3 years.
• This does not offer a level playing field
• Insurers should think and be allowed to offer
health savings product including indemnity
benefit.
• ANY MORE?????