TYPES OF HEALTH INSURANCE COVERAGE
Types of health insurable or the fundamental policies
issued by the insurance companies aiming to meet the requirements of general
public are:
Medical expenses insurance: Basic hospitalization expenses
are reimbursed. It covers payment of expenses related to hospitalization and the
services rendered by the doctor and nursing home/hospital. Under these
insurance schemes, the amin benefit is that predetermined number of days stay
and hospital costs are covered.
Disability income cover: is primarily aimed at providing
for the lost income during the disability period or during the treatment period.
It tries to replace the income that cannot be earned due to sickness of the assured.
The benefit is usually paid as a percentage of the capital sum insured and is
paid weekly. The period for such compensation is short.
Long term care insurance: covers expenses related to major
surgery or operations due to serious illness or disease. Major medical coverage
continues protection after basic medical expenses insurance benefits have
exhausted. It may add some benefits for services which is not covered by
medical expenses cover. Insurance companies provide long term insurance in two
major categories: Nursing home care and Community care. In community care, long
term care policy provides benefit payments for the insured individuals who require
assistance and stay in their homes.
Some of the popular policies are:
Individual Mediclaim Policy: also called as Hospitalization
Benefit Policy. It provides reimbursement of medical expenses incurred towards
hospitalization anywhere within India in case of sudden illness or accident and
extends to pre-hospitalization of 30 days and post hospitalization of 60 days. This
policy is available to any person in the age group of 5 to 80 years. However,
children below 5 years but not below the age of 3 months can also be covered as
long as one or both of the parents are covered at the same time. reimbursement is
not commonly used as a claim settlement system in Mediclaim, and permitted only
when the treatment is taken at a hospital or that meets the criteria prescribed
in the policy
Group Mediclaim Policy: is available to any corporate association,
institution and group of people provided they form the minimum number of
persons to be covered under the policy. The policy holder of this type of insurance
is the group itself and the premiums are payable by the group.
Overseas Mediclaim Policy: is particularly tailored to
protect persons undertaking genuine overseas trips for business or holidays or
studies or employment purpose. The benefit of the policy is that premium is
payable in Indian currency while claims abroad are payable in foreign currency.
Originally introduced in public sector general insurance companies in 1984 the
policy was modified in 1991 and revised Videsh Yatra Mitra Policy was
introduced in 1998. The final version of the policy covers several aspects of foreign
travel that go beyond the ordinary such as loss of passport, personal accident,
etc.
Other covers are:
Jan Arogya Bima Policy
Cancer Insurance
Bhavishya Arogya Policy
Hospital cash daily allowance policy, etc
TYPES OF HEALTH INSURANCE SCHEMES / PROGRAMS IN INDIA
Government or State based System: The largest system of health
care is financed and managed by the central and state government of India. It delivers
health care to the public through the diverse network of hospital, government
hospitals, primary health centres, community health centers, dispensaires and
speciality facilities. These facilities are officially available to the entire
population either for free or for nominal charges. The central Government has
been the main source of funds for primary health care facilities, whereas the
states bear the major responsibility of recurrent costs, especially the costs
of running hospitals, CGHS and ESIS as part of government schemes.
Central Government Health Scheme (CGHS): was introduced in
1954 as a contributory health scheme to provide comprehensive medical care to
the Central Government employees and their families. Separate dispensaries are
maintained for the exclusive use of the central government employees covered by
the scheme. The list of beneficiaries includes all categories of current as well
as former government employees, members of parliament and so on.
Employees State Insurance Scheme (ESIS): was introduced in
1948. This is an insurance system which provides both the cash and the medical
benefits. It is managed by the Employees State Insurance Corporation (ESIS), a
wholly government owned enterprise. It was made as a compulsory social security
benefit for the workers I the formal sector. Now it includes all such factories
which are not using power and employing 20 or more persons. Mines and plantations
are excluded under this scheme.
Market Based System
General Insurance Corporation (GIC) Mediclaim Coverages:
The GIC holds a major share in the market based health insurance segment. It introduced
the Standard Mediclaim health insurance scheme in 1986, and became operational
in 1987. This product was later on modified I 1997 to allow for premium differentials
for various age groups meant for both individuals and groups. It provides
various products like Mediclaim / Hospitalization Benefit Insurance Policy and
Bhavishya Arogya Insurance Policy.
LIC Coverage: The Life Insurance Corporation of India introduced
a special insurance programme in 1993 which covered medical expenses only from
critical diseases. The plan provides health insurance against certain specified
health risks and offers a great financial support during an urgent need or
demand. Following are the key features of this plan,
- Substantial
Financial Protection in case of hospitalization or surgery
- Lump sum
benefit irrespective of actual medical costs
- Increased
health cover every year
- No claim
bonus
- One can
choose various flexible benefits
- One can
also choose various premium payment options
This health insurance plan provides various benefits like
Hospital Cash benefit, day care procedure benefit, major surgical benefit, other
surgical benefit, ambulance benefit and premium waiver benefit.
Private Insurance Company: The insurance sector was opened
for private participation in 2000. Now, private players have largely existed in
group health market. The private sector today provides nearly 80% of outpatient
care and about 60% of inpatient care. Some private insurance companies are Star
Health Insurance, Apollo Munich Health Insurance, Cigna TTK, Reliance General Insurance
Co, etc. These companies provide various health insurance plans to the public.
Employer Provided Insurance System: Employer managed health
facilities and the reimbursement of health expenses by employers are the other
means of health insurance in India. Generally, the public sector undertakings
and big industrial houses have their own hospital and provide medicines etc.,
across the counter, normally, within the company premises / township. In addition,
there are various medical reimbursemnte plans offered by employers for private
medical expenses in the private sector like commercial bank, autonomous
institutions, etc. Some organizations may have self-insurance system known as
medical benefit or medical allowance system. Insurance coverage under this
system vary according to the employee’s salary or designation. Overall, the performance
of this system in India has been satisfactory.
NGO System: In India, health facilities are also provided
by voluntary and charitable or non-governmental organizations (NGOs) like
Self-Employed Women’s’ Association (SEWA), Child in Need Institute (CNI) etc.
The health care facilities offered by these organizations is a part of their
main objectives. Most of the time they create awareness and associate themselves
wit the major health insurers.
