HEALTH INSURANCE SECTOR IN INDIA: CURRENT SCENARIO Essay

1.1 Introduction wellness and health business organisation motif to be distinguished from each other for no better fountain than that the former is often incorrectly seen as a direct hunt down of the latter. Heath is clearly not the mere absence of sickness. Good health confers on a nighbody or groups freedom from illness and the faculty to realize unitys potential. health is thitherfore best undersas welld as the indispensable groundwork for defining a persons sense of well be. The health of populations is a distinct key geld in creation policy discourse in every senesce society often determining the deployment of huge society.They let in its cultural reason of ill health and well- being, extent of socio-economic disparities, reach of health services and tincture and constitutes of cope. and current bio-mcdical understanding nigh health and illness. wellness bursting charge come homes not merely medical fright but besides solely aspects pro preventive assistance too. Nor female genital organ it be restrain to c atomic turn of events 18 rendered by or financed out of existence white plague- within the government empyrean alone but must(prenominal)include incentives and disincentives for self c atomic number 18 and c be remunerative for by private citizens to get over ill health.Where, as in India, private out-of-pocket expenditure dominates the cost financial backing health c are, the effects are bound t be regressive. Heath care at its essential core is widely recognise to be a public good. Its demand and supply cannot therefore, be left to be modulate solely by the invisible had of the market. Nor can it be realised on considerations of utility maximizing conduct alone.1 Health damages in a narrow sense would be an separate or group get health care reporting in advance by paid a fee c altogethered superior.In its broader sense, it would be any arrangement that helps to defer, delay, inhibit or altogether avoi d salary for health care incurred by idiosyncratics and households. presumption the appropriateness of this definition in the Indian context, this is the definition, we would adopt. The health indemnity market in India is very limited administering about 10% of the total population. 1.2 HypothesisThe Researcher assumes that all projections of health care in India must in the end rest on the overall changes in its political economy on progress made in poorness mitigation (health care to the poor) in reduction of inequalities (health inequalities affecting access/ lumber), in generation of employment /income streams (to facilitate capacity to pay and to ease up a bun in the oven individual responsibility for ones health ) in public information and development communication (to promote preventive self care and risk reduction by conducive demeanor styles ) and in own(prenominal) life style changes. 1.3 Research MethodologyIn this endeavour, both indigenous and secondary sour ces of data have been used to prepare the present paper. Further, it must be noted that the present paper discusses in detail the Indian position in this regard. 1.4 Object The purpose of this paper is to lead the incident exists in a scenario where health care is financed by dint of general revenue revenue, community financing, out of pocket payment and social and private health damages ends.1.5 Scope The Scope this Research is limited to the extent of Indian position in this regard, while ignoring the orthogonal Scope.Chapter-2Health redressHealth insurance in a narrow sense would be an individual or group purchasing health care coverage in advance by paying a fee called reward. In its broader sense, it would be any arrangement that helps to defer, delay, reduce or altogether avoid payment for health care incurred by individuals and households. Given the appropriateness of this definition in the Indian context, this is the definition, we would adopt. The health insurance market in India is very limited covering about 10% of the total population2. The existent lineations can be categorized as (1) willing health insurance schemes or private-for-profit schemes (2) Employer-based schemes(3) indemnity offered by NGOs / community based health insurance, and (4) Mandatory health insurance schemes or government run schemes(namely ESIS, CGHS).32.1 Voluntary health insurance schemes or private-for-profit schemesIn private insurance, buyers are willing to pay support to an insurance company that pools people with similar risks and insures them for health expenses. The key distinction is that the supports are set at a level, which provides a profit to third political party and provider institutions. Premiums are based on an assessment of the risk location of the consumer (or of the group of employees) and the level of pull ins provided, rather than as a proportion of the consumers income. 4In the public sector, the General indemnification Corporation (GIC) and its four-spot subsidiary companies (National Insurance Corporation, New India Assurance come with, Oriental Insurance Company and United Insurance Company) and the Life Insurance Corporation (LIC) of India provide involuntary insuranceschemes.The Life Insurance Corporation offers Ashadeep end II and Jeevan Asha Plan II. The General Insurance Corporation offers Personal Accident policy, Jan Arogya policy, Raj Rajeshwari policy, Mediclaim policy, Overseas Mediclaim policy, pubic louse Insurance policy, Bhavishya Arogya policy and Dreaded Disease policy (Srivastava 1999 as quoted in Bhat R & Malvankar D, 2000)Of the various schemes offered, Mediclaim is the main product of the GIC. The Medical Insurance precis or Mediclaim was introduced in November 1986 and it covers individuals and groups with persons aged 5 80 yrs. Children (3 months 5 yrs) are cover with their parents. This scheme provides for reimbursement of medical expenses (now offers cashless scheme) by an i ndividual towards hospitalization insurance and domiciliary hospitalization as per the sum insured.There are exclusions and pre-existing disease clauses. Premiums are calculated based on age and the sum insured, which in turn varies from Rs 15 000 to Rs 5 00 000. In 1995/96 about half(prenominal) a million Mediclaim policies were issued with about 1.8 million beneficiaries (Krause Patrick 2000). The coverage for the category 2000-01 was well-nigh 7.2 million.Another scheme, namely the Jan Arogya Bima policy specifically targets the poor population groups. It also covers reimbursement of hospitalization costs up to Rs 5 000 annually for an individual premium of Rs 100 a year. The selfsame(prenominal) exclusion mechanisms habituate for this scheme as those under the Mediclaim policy. A family discount of 30% is granted, but there is no group discount or agent commission. However, similar the Mediclaim, this policy too has had only limited success. The Jan Arogya Bima Scheme had only cover 400 000 individuals by 1997.The year 1999 marked the beginning of a new era for health insurance in the Indian context. With the passing of the Insurance Regulatory teaching Authority Bill (IRDA) the insurance sector was opened to private and foreign participation, thereby paving the way for the admittance of private health insurance companies. The Bill also facilitated the establishment of an authority to protect the interests of the insurance holders by regulating, promoting and ensuring orderly growth of the insurance industry. The billallows foreign promoters to hold paid up capital of up to 26 percent in an Indian company and requires them to have a capital of Rs 100 crore along with a business plan to begin its operations.Currently, a few companies such as Bajaj Alliance, ICICI, proud Sundaram, and Cholamandalam among others are offering health insurance schemes. The nature of schemes offered by these companies is described briefly.5Bajaj Allianz Bajaj Allianz offers three health insurance schemes namely, Health defy, Critical nausea Policy and Hospital Cash Daily Allowance Policy. The Health Guard scheme is on hand(predicate) to those aged 5 to 75 years (not allowing entry for those over 55 years of age), with the sum assured ranging from Rs 100 0000 to calciferol 000.It offers cashless win and medical reimbursement for hospitalization expenses (preand post-hospitalization) at various hospitals across India (subject to exclusions and conditions). In case the member opts for hospitals besides the empanelled ones, the expenses incurred by him are reimbursed within 14 working sidereal days from submission of all the written documents.While pre-existing diseases are excluded at the time of taking the policy, they are covered from the 5th year onwards if the policy is continuously renewed for four years and the same has been declared while taking the policy for the first time. Other discounts and benefits same(p) tax exemption, health check-up at end of four claims free year, and so on can be availed of by the insured. The Critical Illness policy pays benefits in case the insured is diagnosed as suffering from any of the listed critical events and survives for minimum of 30 days from the date of diagnosis. The illnesses covered include first pith attack Coronary artery disease requiring operating room stroke genus Cancer kidney failure major organ transplantation multiple sclerosis surgery on aorta primary pulmonary arterial hypertension, and paralysis. While exclusion clauses apply, premium rates are competitive and high-sum insurance can be opted for by the insured. The Hospital Cash Daily Allowance Policy provides cash benefit for each and every completed day of hospitalization, due to sickness or accident. The amount due per day is lookant on the selected scheme. Dependant cooperatorand children (aged 3 months 21years) can also be covered under the Policy. The benefits payable to the dependants are l inked to that of insured.The Policy pays for a maximum single hospitalization period of 30 days and an overall hospitalization period of 30/60 completed days per policy period per person unheeding of the number of confinements to hospital/nursing home per policy period. ICICI Lombard ICICI Lombard offers Group Health Insurance Policy.This policy is available to those aged 5 80 years, (with children being covered with their parents) and is given to corporate bodies, institutions, and associations. The sum insured is minimum Rs 15 000/- and a maximum of Rs 500 000/-. The premium chargeable depends upon the age of the person and the sum insured selected. A slab wise group discount is admittible if the group size exceeds 100. The policy covers reimbursement of hospitalization expenses incurred for diseases contracted or injuries carry on in India. Medical expenses up to 30 days for Pre-hospitalization and up to 60 days for post-hospitalization are also admissible. Exclusion clauses apply.Moreover, favourable claims experience is recognized by discount and conversely, unfavourableclaims experience attracts loading on renewal premium. On payment of additional premium, the policy can be extended to cover maternity benefits, pre-existing diseases, and reimbursement of cost of health check-up after four sequentially claims-free years.Royal Sundaram Group The Shakthi Health Shield policy offered by the Royal Sundaram group can be availed by members of the womens group, their spouses and dependent children. No age limits apply. The premium for adults aged up to 45 years is Rs one hundred twenty-five per year, for those aged more(prenominal) than 45 years is Rs 175 per year. Children are covered at Rs 65 per year. Under this policy, hospital benefits up to Rs 7 000 per annum can be availed, with a limit per claim of Rs 5 000. Other benefits include maternity benefit of Rs 3 000 subject to waiting period of niner months after first document and for first two child ren only. Exclusion clauses apply (Ranson K & Jowett M, 2003)Cholamandalam General Insurance The benefits offered (in association with the Paramount Health Care, a re-insurer) in case of an illness or accident resulting in hospitalization, are cash-free hospitalization in more than 1400 hospitals across India, reimbursement of the expenses during pre- hospitalization (60 days prior to hospitalization) and post- hospitalization (90 days after discharge) stages of treatment. Over one hundred thirty minor surgeries that require less than 24 hours hospitalization under day care procedure are also covered.Extra health covers like general health and eye examination, local ambulance service, hospital daily allowance, and 24 hours assistance can be availed of. Exclusion clauses apply. Employer-based schemes.Employers in both the public and private sector offers employer-based insurance schemes through their own employer-managed facilities by way of lump sum payments, reimbursement of emplo yees health expenditure for outpatient care and hospitalization, opinionated medical allowance, monthly or annual irrespective of actual expenses, or covering them under the group health insurance policy. The railways, defence and protective covering forces, plantations sector and mining sector provide medical services and / or benefits to its own employees. The population coverage under these schemes is minimal, about 30-50 million people.2.2 Insurance offered by NGOs / community-based health insuranceCommunity-based funds refer to schemes where members prepay a set amount each year for specified services. The premia are commonly flat rate (not income- striked) and therefore not progressive. Making profit is not the purpose of these funds, but rather improving access to services. Often there is a problem with unseemly selection because of a large number of high-risk members, since premiums are not based on assessment of individual risk status. Exemptions may be adopted as a sub ject matter of assisting the poor, but this will also have adverse effect on the ability of the insurance fund to meet the cost of benefits.6Community-based schemes are typically targeted at poorer populations living in communities, in which they are involved in defining contribution level and collecting mechanisms, defining the content of the benefit package, and / or allocating the schemes, financial resources (International Labour Office Universities Programme 2002 as quoted in Ranson K & Acharya A, 2003).Such schemes are generally run by religious belief hospitals or nongovernmental organizations (NGOs). The benefits offered are mainly in terms of preventive care, though ambulatory and in-patient care is also covered. Such schemes tend to be financed through patient collection, government grants and donations. Increasingly in India, CBHI schemes are negotiating with the forprofit insurers for the purchase of bespoken designed group insurance policies.However, the coverage of s uch schemes is low, covering about 30-50 million (Bhat, 1999). A re trip up by Bennett, Cresse et al. (as quoted in Ranson K & Acharya A, 2003) indicates that many a(prenominal) community-based insurance schemes suffer from poor design and management, fail to include the poorest-of-thepoor, have low membership and require extensive financial support. Other issues relate to sustainability and replication of such schemes. Some examples of community-based health insurance schemes are discussed hereinSelf-Employed Womens Association (SEWA), Gujarat This scheme established in 1992, provides health, life and assets insurance to women working in the informal sector and their families. The enrolment in the year 2002 was 93 000. This scheme operates in collaboration with the National Insurance Company (NIC). Under SEWAs most popular policy, a premium of Rs 85 per individual is paid by the woman for life, health and assets insurance. At an additional payment of Rs 55, her husband too can be covered. Rs 20 per member is then paid to the National Insurance Company (NIC) which provides coverage to a maximum of Rs 2 000 per person per year for hospitalization.After being hospitalized at a hospital of ones choice (public or private), the insurance claim is submitted to SEWA. The responsibility for enrolment of members, for processing and approving of claims rests with SEWA. NIC in turn receives premiums from SEWA annually and pays them a lumpsum on a monthly basis for all claims reimbursed.The phone numberion for Community Organization, Rehabilitation and Development (ACCORD) Nilgiris, Tamil Nadu was established in 1991. Around 13 000 Adivasis (tribals) are covered under a group policy purchased from New India Assurance.Another scheme located in Tamil Nadu is Kadamalai Kalanjia Vattara Sangam (KKVS) Madurai. This was established in 2000 and covers members of womens self-help groups and their families. Its enrolment in 2002 was well-nigh 5 710, with the KKVS functioning as a third party insurer.The Voluntary Health Services (VHS) Chennai, Tamil Nadu was established in 1963. It offers sliding premium with free care to the poorest. The benefits include discounted rates on both outpatient and con care, with the VHS functioning as both insurer and health care provider. In 1995, its membership was 124 715. However, this scheme suffers from low levels of cost recovery due to problems of adverse selection.2.3 Social Insurance or mandatory health insurance schemes or government run schemes (namely the ESIS, CGHS)Social insurance is an earmarked fund set up by government with explicit benefits in return for payment. It is usually arrogant for certain groups in the population and the premiums are determined by income (and consequently ability to pay) rather than related to health risk. The benefit packages are order and contributions are earmarked for spending on health services The government-run schemes include the cardinal presidency Health Scheme (CGH S) and the Employees enounce Insurance Scheme (ESIS). underlying giving medication Health Scheme (CGHS) Since 1954, all employees of the Central Government (present and retired) some autonomous and semi-government organizations, MPs, judges, freedom fighters and journalists are covered under the Central Government Health Scheme (CGHS). This scheme was designed to re flummox the cumbersome and costly system of reimbursements (GOI, 1994). It aims at providing comprehensive medical care to the Central Government employees and the benefits offered include all outpatient facilities, and preventive and encouraging care in dispensaries. yard bird facilities in government hospitals and approved private hospitals are also covered. This scheme is mainly funded through Central Government funds, with premiums ranging from Rs 15 to Rs 150 per month based on salary scales. The coverage of this scheme has grown considerably with provisionfor the non-allopathic systems of medicine as well as f or allopathy. Beneficiaries at this indorsement are around 432 000, spread across 22 cities.The CGHS has been criticized from the point of view of tint and accessibility. Subscribers have complained of high out-of-pocket expenses due to slow reimbursement and neither coverage for private health care (as only 80% of cost is reimbursed if referral is made to private facility when such facilities are not available with the CGHS).7 Employee and State Insurance Scheme (ESIS) The enactment of the Employees State Insurance Act in 1948 led to formulation of the Employees State Insurance Scheme. This scheme provides testimonial to employees against loss of wages due to inability to work due to sickness, maternity, baulk and death due to employment injury.It offers medical and cash benefits, preventive and promotive care and health education. Medical care is also provided to employees and their family members without fee for service. Originally, the ESIS scheme covered all power-using no n-seasonal factories employing 10 or more people. Later, it was extended to cover employees working in all non-power using factories with 20 or more persons. While persons working in mines and plantations, or an organization offering health benefits as good as or better than ESIS, are specifically excluded. Service establishments like shops, hotels, restaurants, cinema houses, road transport and news text file printing are now covered.The monthly wage limit for enrolment in the ESIS is Rs. 6 500, with a prepayment contribution in the form of a payroll tax of 1.75% by employees, 4.75% of employees wages to be paid by the employers, and 12.5% of the total expenses are borne by the state governments. The number of beneficiaries is over 33 million spread over 620 ESI centres across states. Under the ESIS, there were one hundred twenty-five hospitals, 42 annexes and 1 450 dispensaries with over 23 000 beds facilities.The scheme is managed and financed by the Employees State Insurance C orporation (a public undertaking) through the state governments, with total expenditure of Rs 3 300 million or Rs 400/- per capita insured person. The ESIS platform has attracted considerable criticism. A report based on patient surveys conducted in Gujarat (Shariff, 1994 as quoted in Ellis R et a, 2000) found that over half of those covered did not seek care from ESIS facilities. Unsatisfactory nature of ESIS services, low fiber drugs, long waiting periods, impudent behaviour of personnel, lack of interest or low intereston part of employees and low awareness of ESI procedures, were some of the reasons cited.8Chapter-3ConclusionThe challenge for the Indian policy-makers is to find ways to improve upon the existing situation in the health sector and to make equitable, affordable and quality health care accessible to the population, especially the poor and the vulnerable sections of the society.It is in a way inevitable that the state reforms its public health pitch system and exp lores other social security options like health insurance. Implementing regulations would be one, but by no means the best mechanism to take for provider behaviour and costs. This can only be done by developing mechanisms where government and households can together pool their funds. This could be one way of controlling provider behaviour.There is an urgent need to document global and Indian experiences in social health insurance. Different financing options would need to be developed for different target groups. The wide differentials in the demographic, epidemiological status and the delivery capacity of health systems are a serious constraint to a nationally mandated health insurance system. Given the heterogeneity of different regions in India and the regional specifications, one would need to start pilot projects to gather more information about the population to be targeted under an insurance scheme and develop options for different population groups.Health policy-makers and health systems research institutions, in collaboration with economic policy study institutes, need to gather information about the prevailing disease kernel at various geographical regions to develop standard treatment guidelines, to seek costing of health services for evolving benefit packages to determine the premium to be levied and subsidies to be given and to map health care facilities available and the institutional mechanisms which need to be in place, for implementing health insurance schemes.Skillbuilding for the personnel involved, and capacity-building ofall the stakeholders involved, would be a critical component for ensuring the success of any health insurance programme.The success of any social insurance scheme would depend on its design, the implementation and monitoring mechanisms which would be set in place and it would also call for restructuring and reforming the health system, and developing the necessary prerequisites to ensure its success.