Overview

Health insurance is also known as Medical insurance in insurance terminology. Health insurance in India comes under the General Insurance umbrella and is guided by the regulations of IRDA (Insurance Regulatory Development Authority). The insurance act introduced in the year 1938  laid down the rules and regulations and had a few changes till 1972. After Nationalisation, 107 insurance companies were brought under General Insurance Corporation(GIC). The Insurance Regulatory Authority (IRDA) in its current form is formed in the year 1999.

Current Status of Health Insurance Industry in India

Health insurance is growing at an average rate of 35% year after year since 2005 and the gross written premium has grown from 2200 Crores to 9600 crores ( since 2005 till the year 2011).The contribution of health insurance to the general insurance business doubled in 6 years from a 10% to 20% level. The health insurance industry is estimated to touch 30000 crores by the year 2015. The current penetration levels of health insurance in india is not more than 6%.

Health Insurance – Defined

Health insurance is defined as the cover that pays for the medical and surgical expenses when caused by illness or bodily injury to the insured.

Health Insurance types in India

Health insurance is divided into three types in India

1)    Social

2)    Community Based also known as Micro insurance

3)    Private

Social Health Insurance (SHI) is a mandatory insurance initiative by the government of India and is considered as non risk rated.Examples of these health insurance schemes are ESIS( Employees state Insurance Scheme) and CGHS( Central Government Health Scheme)

ESIS( Employees state Insurance Scheme)

1)    This scheme is applicable to Factory set up type of employees and their dependants with income less than Rs 7500 per month

2)    This scheme is in force since the year 1948 and is applicable to all establishments with a work force of 10 employees or more.

3)    This covers the health related expenses,sickness, maternity, permanent disability of self or dependent also covers the funeral expenses, rehabilitation allowance, hospitalization, outpatient care or special treatment it also covers the expenses of Indian medicine systems such as ayurveda, unani.

4)    The contribution to provide the cover for the employees comes from employees,employers and the respective state government.

Also Read our cost and benefit analysis of Health Insurance with Maternity Coverage

Central Government Health Scheme (CGHS)

1)    The CGHS scheme has come into force in the year 1954

2)    The employees and dependants of the Central Government both working and retired, Semi Government organisation, some Autonomous institutions, MP’s( member of parliament), journalists, freedom fighters are covered under this scheme.

3)    Most of the contribution of this scheme comes from the Central Government and a nominal amount from the employees’ salaries

4)    All sorts of medical care facilities is provided including free medicines at CGHS dispensaries and special Indian treatments such as ayurveda, homeopathy, unani are also covered.

Community Health Insurance schemes/ Micro Insurance

Community health insurance schemes (CHI) have come into existence to help the poor for their health care needs and protecting them from racking up huge medical expenses in the semi urban and rural areas.

1)    Community health insurance and Micro insurance are used synonymously focussing on the low earning strata of the population who are not covered under any of the health insurance schemes provided by the state or central government.

2)    This works on risk pooling methodology and voluntary basis.

3)    The micro insurance addresses small communities or groups for covering their health care needs.

4)    Public sector companies were majorly playing the role in providing the micro insurance or rural insurance off late private insurers like ICICI Lombard, starhealth etc have come forward to promote the micro insurance.

5)    The health risks such as hospitalisation, primary health care, maternity, disability can be covered.

Private Health Insurance

Post liberalisation, many private insurers have entered the market of health insurance with different names and the term health insurance is made popular otherwise till then it is most popularly known as “Mediclaim policy”

Mediclaim policy is further divided into

a)    Individual policy

b)    Group Mediclaim policy ( also known as GMC)

With only minor changes , all insurers have the following in common in their health insurance covers.

1)    The policies provide the reimbursement of Hospitalisation for illness, diseases suffered or accidental injury sustained during the policy period

2)    The expenses covered are Room, boarding expenses in the hospital, Nursing expenses, doctors fees( surgeon,anasthesian, consultants etc) medicines and other expenses for tests such as X ray,blood oxygen etc cost of organs, limbs

3)    All the expenses should not exceed the limit of the sum insured on the individual.

4)    All of the above expenses are covered subject to a minimum period of 24 hrs of hospitalisation.

5)    However there are certain treatments which don’t require 24hrs hospitalisation such as dialysis, eye surgery, chemotherapy, kidney stone removal (lithotripsy) etc these are considered under hospitalisation benefit.

6)    Medical expenses incurred 30 days prior to the hospitalisation and 60 days after hospitalisation are considered subject to the treatment done for a specific disease.

Exclusions

1)    All the diseases and injuries which are pre-existing before the inception of the policy are not covered.

2)    Diseases contracted during the first 30 days of the policy are excluded.

1^st Year Exclusions

The policy doesn’t cover certain diseases which are mentioned below during the first year

1)Cataract,Benign prostratic hyperthropy,Fibromyoma, Hernia, Hydrocele, Fistula, Piles,sinsusitis.If these diseases are pre-existing during the inception of the policy, they will not be covered during subsequent years also. How ever some of the insurers may cover pre-existing diseases after 4 years if the customer still avails the health insurance of that Insurer.

Group Mediclaim Policy.

Group Mediclaim policy is for any group/association/institution/organisation where the policy is issued in the name of the corporate body(insured) with scheduled names of members  including the family members

1)    Corporate which provide health insurance to their employees fall under this category

2)    Maternity benefit is extended under this policy.

Summary

Health insurance in India is gaining importance since 2001 and has been  growing sector with each year. The underwriting premiums are expected to contribute to more than 20% to the overall general insurance business. India is one of the least penetrated markets in terms of health insurance when compared with the developed and developing countries though awareness is building up in the urban areas.However there is lot more to catch up in the semi urban and rural areas.

Senior Citizen- Health Insurance

A person who reaches an age of 60 years is known as senior citizen in India. Approximately 22% of the Indian population are senior citizens. As the person reaches the age of 60, he/she is prone to more diseases and at times with critical illnesses. Hence it becomes all the more important that a person should have a health insurance cover at this age since the earnings of the person may come down and may eat up the savings when an illness hits. The treatment will prove  to be costly affair.

Many of the insurers were reluctant to give any health insurance policy once the person approaches an age of 60 in the past as they may face more claims but thanks to some of the government initiatives, many of the public and private insurers are offering the health insurance cover for the senior citizens.

CGHS (Central Government Health scheme)

The CGHS scheme was brought into effect way back in the year 1954. In which it covers the health care needs of the employees of the central government, semi government organizations, some recognised autonomous organisations, MP’s, accredited journalists, and freedom fighters etc are covered while they are working and even after they are retired. The central government contributes to a huge extent for the health care needs. People retired from the above said organisations and who are now the senior citizens will have the facility at all the CGHS dispensaries for their health needs such as free medicines, ayurveda, unani and homeopathy as the case of treatment may be.

The National Health Policy -1999

Year 1999 was considered as “the international year of Older Persons” keeping in view the government of India had taken an initiative of launching National health policy for senior citizens. The goal of this policy was to provide affordable, good and subsidized health services to the senior citizens and will be promoted through organisations which are of non- profit nature and also encouraged by the state governments in their respective states.

The basic idea is to provide preventive, curative and rehabilitative health services to the senior citizens of the country. Some of the important points to be noted in this facility are

1)    Treatment and separate quota of beds in case of hospitalisation in all district hospitals

2)    Health insurance to all the senior citizens who are above 80 and are not able to pay income tax through public funded schemes

3)    Offering subsidies to NGO’s who provide mobile health clinics and offering health care services to the senior citizens

4)    Apart from the above the educating the senior citizens about health care needs through different programmes and providing them a sense of “ Health Aging”

5)    The Insurance Regulatory Authority has also made an important instruction that no insurance company should deny the health insurance policy of the senior citizens and explanation quoting with the reasons should be given when asked for in case of policy denial. The authority has also relaxed the age from 60 to 65 for senior citizens so that they can buy their first policy even at the age of 65 to get covered for their health needs.

Health Policies offered by the Insurance companies for senior citizens –

 Health insurance for senior citizens is offered by public and private insurers.

1)   Varishtha Mediclaim – The National insurance company

 a)Entry Age Limit – 60 – 80 years

b)Sum Assured – Rs 1,00,000 with domiciliary hospitalisation and  Rs 2,00,000 with Critical illness cover(Coronary Artery Surgery Cancer Stroke Multiple Sclerosis Organ transplants, paralysis and blindness) are covered.

c) Ambulance charges Rs1000

The key benefits of this policy are one can buy the health insurance starting from the age of 60 years but the premiums will go up as the policy is bought at a later age.

The policy also covers the critical illness and the premiums for this cover are additional.

2)Mediclaim Policy – The New India Assurance Company

a)    Entry Age limit – 60-80

b)    Sum assured – Rs 1,00,000 and Rs 2,00,000

c)    10% family bonus if both husband and wife are covered in this policy

d)    5% bonus on renewal of the policy

e)    Pre hospitalisation expenses upto 30 days and post hospitalisation expenses upto 60 days are covered

3)   Senior Citizen Diseases Insurance – The Oriental Insurance company- HOPE

a)    Entry age limit – 60 and above

b)   Sum assured – Rs 1,00,000 to Rs5,00,000

c)    Covers only specific diseases

d)    Compulsory co-payment of 20% on admissible claim amount

e)    No claim discount on premium

f)     Cashless service through TPA limited to 1 lakh only

g)    In cases of accidents 100% of the sum assured is paid, 70% for knee replacement,50% for cardi vascular , chronic renal failure,cancer,hepato- biliary disorder, 20% of sum assured in case of stroke,chronic obstructive lung diseases,15% for benign prostrate and orthopaedic diseases and 10% for ophthalmic diseases.

4)   Health insurance for Senior citizens – United India Insurance

a)    Entry Age 61- 80

b)    Sum assured – Rs 50,000 to Rs 3,00,000

c)    Tax benefits under section 80D for premiums paid up to Rs 20,000

Apart from the Public insurers, the private insurers also have health insurance policies for senior citizens in their portfolio. Ex Star health’s senior citizen redcarpet insurance plan and Bajaj Allianz’s silver health.

Summary

Senior Citizens and their health care is vital as they have served the nation in their own capacity and are part of building up the nation. The Government of India under article 41 stresses on the same. The subject matter given above is only a gist of the policies available with different insurance companies however the reader is advised to study the policy guidelines in details specially the exclusions of each policy before buying any health insurance policy for self or for their elders who are senior citizens.