HEALTH INSURANCE

IN INDIA

Jaideep Kumar

MPH 2nd Semester

Contents:
1 .Introduction
2. Public health and Health insurance
3. History and evolution
4. Insurance Acts in India
5. Insurance schemes in India
6. Comparison
o Australia
o Canada
o France
o Netherlands
o United Kingdom
o United States
7. Conclusion
8. Refrences
1.Introduction:-

Health Insurance
Health insurance in a narrow sense would be ‘an individual or group purchasing health
care coverage in advance by paying a fee called premium.’ 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.

How it works:-

A health insurance policy is a contract between an insurance company and an individual.

The contract can be renewable annually or monthly. The type and amount of health care
costs that will be covered by the health plan are specified in advance, in the member
contract or Evidence of Coverage booklet. The individual policy-holder's payment
obligations may take several forms.

• Premium: The amount the policy-holder pays to the health plan each month to
purchase health coverage.
• Deductible: The amount that the policy-holder must pay out-of-pocket before the
health plan pays its share. For example, a policy-holder might have to pay a 500
/-rupees deductible per year, before any of their health care is covered by the
health plan. It may take several doctor's visits or prescription refills before the
policy-holder reaches the deductible and the health plan starts to pay for care.
• Copayment: The amount that the policy-holder must pay out of pocket before the
health plan pays for a particular visit or service. For example, a policy-holder
might pay a 50/-Rs copayment for a doctor's visit, or to obtain a prescription. A
copayment must be paid each time a particular service is obtained.
• Coinsurance: Instead of paying a fixed amount up front (a copayment), the
policy-holder must pay a percentage of the total cost. For example, the member
might have to pay 20% of the cost of a surgery, while the health plan pays the
other 80%. Because there is no upper limit on coinsurance, the policy-holder can
end up owing very little, or a significant amount, depending on the actual costs of
the services they obtain.
• Exclusions: Not all services are covered. The policy-holder is generally expected
to pay the full cost of non-covered services out of their own pocket.
• Coverage limits: Some health plans only pay for health care up to a certain dollar
amount. The policy-holder may be expected to pay any charges in excess of the
health plan's maximum payment for a specific service. In addition, some plans
have annual or lifetime coverage maximums. In these cases, the health plan will
stop payment when they reach the benefit maximum and the policy-holder must
pay all remaining costs.
• Out-of-pocket maximums: Similar to coverage limits, except that in this case,
the member's payment obligation ends when they reach the out-of-pocket
maximum, and the health plan pays all further covered costs. Out-of-pocket
maximums can be limited to a specific benefit category (such as prescription
 drugs) or can apply to all coverage provided during a specific benefit year.
• Capitation: An amount paid by an insurer to a health care provider, for which the
provider agrees to treat all members of the insurer.
• In-Network Provider: A health care provider on a list of providers preselected
by the insurer. The insurer will offer discounted coinsurance or copayments, or
additional benefits, to a plan member to see an in-network provider. Generally,
providers in network are providers who have a contract with the insurer to accept
rates further discounted from the "usual and customary" charges the insurer pays
to out-of-network providers.
• Prior Authorization: A certification or authorization that an insurer provides
prior to medical service occurring. Obtaining an authorization means that the
insurer is obligated to pay for the service, assume it matches what was authorized.
Many smaller, routine services do not require authorization.
• Explanation of Benefits: A document sent by an insurer to a patient explaining
what was covered for a medical service, and how they arrived at the payment
amount and patient responsibility amount.

2.Public health and Health insurance:-

The health care system in India is characterised by multiple systems of medicine, mixed
ownership patterns and different kinds of delivery structures. Public sector ownership is
divided between central and state governments, municipal and Panchayat local
governments. Public health facilities include teaching hospitals, secondary level
hospitals, first-level referral hospitals (CHCs or rural hospitals), dispensaries; primary
health centres (PHCs), sub-centres and health posts. Also included are public facilities for
selected occupational groups like organized work force (ESI), defence, government
employees (CGHS), railways, post and telegraph and mines among others. The private
sector (for profit and not for profit) is the dominant sector with 50 per cent of people
seeking indoor care and around 60 to 70 per cent of those seeking ambulatory care (or
outpatient care) from private health facilities. While India has made significant gains in
terms of health indicators - demographic, infrastructural and epidemiological), it
continues to grapple with newer challenges. Not only have communicable diseases
persisted over time but some of them like malaria have also developed insecticide-
resistant vectors while others like tuberculosis are becoming increasingly drug resistant.
HIV / AIDS have of late assumed extremely virulent proportions. The 1990s have also
seen an increase in mortality on account of non-communicable diseases arising as a result
of lifestyle changes. The country is now in the midst of a dual disease burden of
communicable and noncommunicable diseases. This is coupled with spiralling health
costs, high financial burden on the poor and erosion in their incomes. Around 24% of all
People hospitalized in India in a single year fall below the poverty line due to
hospitalization (World Bank, 2002). An analysis of financing of hospitalization shows
that large proportion of people; especially those in the bottom fourincome quintiles
borrow money or sell assets to pay for hospitalization (World Bank, 2002).
This situation exists in a scenario where health care is financed through general tax
revenue, community financing, out of pocket payment and social and private health
insurance schemes. India spends about 4.9% of GDP on health (WHR, 2002). The per
capita total expenditure on health in India is US$ 23, of which the per capita Government
expenditure on health is US$ 4. Hence, it is seen that the total health expenditure is
around 5% of GDP, with breakdown of public expenditure (0.9%); private expenditure
(4.0%). The private expenditure can be further classified as out-of-pocket (OOP).
Expenditure (3.6%) and employees/community financing (0.4%). It is thus evident that
public health investment has been comparatively low. In fact as a percentage of GDP it
has declined from 1.3% in 1990 to 0.9% as at present. Furthermore, the central budgetary
allocation for health (as a percentage of the total Central budget) has been stagnant at
1.3% while in the states it has declined from 7.0% to 5.5%.In light of the fiscal crisis
facing the government at both central and state levels, in the form of shrinking public
health budgets, escalating health care costs coupled with demand for health-care services,
and lack of easy access of people from the low-income group to quality health care,
health insurance is emerging as an alternative mechanism for financing of health care.

History and evolution:-

In World:-The concept of health insurance was proposed in 1694 by Hugh the Elder
Chamberlen from the Peter Chamberlen family. In the late 19th century, "accident
insurance" began to be available, which operated much like modern disability
insurance. This payment model continued until the start of the 20th century in some
jurisdictions (like California), where all laws regulating health insurance actually
referred to disability insurance. Accident insurance was first offered in the United
States by the Franklin Health Assurance Company of Massachusetts. This firm,
founded in 1850, offered insurance against injuries arising from railroad and
steamboat accidents. Sixty organizations were offering accident insurance in the
US by 1866, but the industry consolidated rapidly soon thereafter. While there were
earlier experiments, the origins of sickness coverage in the US effectively date
from 1890. The first employer-sponsored group disability policy was issued in
1911. Before the development of medical expense insurance, patients were
expected to pay all other health care costs out of their own pockets, under what is
known as the fee-for-service business model. During the middle to late 20th
century, traditional disability insurance evolved into modern health insurance
programs. Today, most comprehensive private health insurance programs cover the
cost of routine, preventive, and emergency health care procedures, and also most
prescription drugs, but this was not always the case. Hospital and medical expense
policies were introduced during the first half of the 20th century. During the 1920s,
individual hospitals began offering services to individuals on a pre-paid basis,
eventually leading to the development of Blue Cross organizations. The
predecessors of today's Health Maintenance Organizations (HMOs) originated
beginning in 1929, through the 1930s and on during World War II.

In India:
The history of insurance in India dates back to 1818. It is in this year that the Oriental
Life Insurance Company was established in Kolkata to meet the requirements of the
European community. During the pre-independent period, India witnessed discrimination
among the life of the Europeans and Indians with more premiums being levied on the
Indians. Bombay Mutual Life Assurance Society was the first to charge normal rate
premiums for the Indians. Several insurance companies were set up in India in the
beginning of the 20th Century. The Life Insurance Companies Act was passed in 1912.
This act made it mandatory to get the periodical valuations and premium rate tables of the
companies sanctioned by an actuary. In spite of this, an disparage remained due to the
discrimination between Foreign and Indian companies. National Insurance Company Ltd,
established in 1906, is India's oldest insurance company.

3.Insurance Acts in India:-

The Insurance Sector in India is regulated by a number of acts. The insurance Acts in
India are as follows:

 The Insurance Act, 1938

 General Insurance Business ( Nationalisation ) Act, 1972
 Life Insurance Corporation Act, 1956
 Insurance Regulatory and Development Authority (IRDA) Act, 1999

4.Existing schemes:-
The health insurance market in India is very limited covering about 10% of the total
population. The existing schemes can be categorized as:
(1) Voluntary health insurance schemes or private-for-profit schemes;
(2) Employer-based schemes;
(3) Insurance offered by NGOs / community based health insurance, and
(4) Mandatory health insurance schemes or government run schemes
( namely ESIS, CGHS).

1. Voluntary health insurance schemes or private-for-profit schemes

In private insurance, buyers are willing to pay premium to insurance company that pools
people with similar risks and insures them for health expenses. The key distinction is that
the premiums are set at a level, which provides a profit to third party and provider
institutions. Premiums are based on an assessment of the risk status of the consumer (or
of the group of employees) and the level of benefits provided, rather than as a proportion
of the consumer’s income. In the public sector, the General Insurance Corporation (GIC)
and its four subsidiary companies (National Insurance Corporation, New India Assurance
Company, Oriental Insurance Company and United Insurance
Company) and the Life Insurance Corporation (LIC) of India provide voluntary Insurance
schemes. The Life Insurance Corporation offers Ashadeep Plan 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, Cancer
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 Scheme 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 covered with their parents. This scheme provides
for reimbursement of medical expenses (now offers cashless scheme) by an individual
towards hospitalization 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.
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 same exclusion mechanisms
apply 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, like the
Mediclaim, this policy too has had only limited success. The Jan Arogya Bima Scheme
had only covered 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 Development Authority Bill
(IRDA) the insurance sector was opened to private and foreign participation, thereby
paving the way for the entry 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 bill allows 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, Royal
Sundaram, and Cholamandalam among others are offering health insurance schemes. The
nature of schemes offered by these companies is described briefly.
Ø Bajaj Allianz: Bajaj Alliance offers three health insurance schemes namely, Health
Guard, Critical Illness Policy and Hospital Cash Daily Allowance Policy.The Health
Guard scheme is available 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 500 000. It offers
cashless benefit 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 days from submission of all
the 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 like tax exemption, health check-up at end of four claims free year,
etc. 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 heart attack; Coronary artery disease requiring surgery: stroke; 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 payable per
day is dependent on the selected scheme. Dependant spouse and children (aged 3 months
– 21years) can also be covered under the Policy. The benefits payable to the dependants
are linked 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 regardless of the number of confinements to hospital/nursing home per
policy period.
Ø 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 admissible
if the group size exceeds 100. The policy covers reimbursement of hospitalization
expenses incurred for diseases contracted or injuries sustained 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, unfavourable claims 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 consecutive claims-free years.
Ø Royal Sundaram Group: The Shakthi Health Shield policy offered by the Royal
Sundaram group can be availed by members of the women’s group, their spouses and
dependent children. No age limits apply. The premium for adults aged up to 45 years is
Rs 125 per year, for those aged more 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 nine months after first enrolment and for
first two children only
Ø 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 1 400 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 130 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.

2.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 employee’s health expenditure for outpatient care and hospitalization,
fixed medical allowance, monthly or annual irrespective of actual expenses, or covering
them under the group health insurance policy. The railways, defence and security 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.

3. Insurance offered by NGOs / community-based health insurance

Community-based funds refer to schemes where members prepay a set amount each year
for specified services. The premium are usually flat rate (not income-related) 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 adverse 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 means of assisting the poor, but
this will also have adverse effect on the ability of the insurance fund to meet the cost of
benefits. Community-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. Such schemes are generally run by trust 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 for-profit insurers for the
purchase of custom designed group insurance policies. However, the coverage of such
schemes is low, covering about 30-50 million (Bhat, 1999). A review by Bennett, Cresse
et al. (as quoted in Ranson K & Acharya A, 2003) indicates that many 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 of the schemes are
described below ;-
Ø Self-Employed Women’s 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 SEWA’s 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 one’s 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.
(Ranson K & Acharya A, 2003).
Ø Another CBHI scheme located in Gujarat, is that run by the Tribhuvandas
Foundation (TF), Anand. This was established in 2001, with the membership being
restricted to members of the AMUL Dairy Cooperatives. Since then, over 1 00 000
households have been enrolled under this scheme, with the TF functioning as a third
party insurer.
Ø The Mallur Milk Cooperative in Karnataka established a CBHI scheme in 1973. It
covers 7 000 people in three villages and outpatient and inpatient health care are directly
provided.
Ø A similar scheme was established in 1972 at Sewagram, Wardha in Maharashtra. This
scheme covers about 14 390 people in 12 villages and members are provided with
outpatient and inpatient care directly by Sewagram.
Ø The Action 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.
Ø Another scheme located in Tamil Nadu is Kadamalai Kalanjia Vattara Sangam
(KKVS), Madurai. This was established in 2000 and covers members of women’s self-
help groups and their families. Its enrolment in 2002 was around 5 710, with the KKVS
functioning as a third party insurer.
Ø 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 inpatient 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.
Ø Raigarh Ambikapur Health Association (RAHA), Chhatisgarh was established in
1972, and functions as a third party administrator. Its membership in the year 1993 was
72 000.

4.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 compulsory for certain groups in the population and the
premiums are determined by income (and hence ability to pay) rather than related to
health risk. The benefit packages are standardized and contributions are earmarked for
spending on health services The government-run schemes include the Central
Government Health Scheme (CGHS) and the Employees State Insurance Scheme (ESIS).
Central Government 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 replace the cumbersome and expensive 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 promotive care in dispensaries. Inpatient 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 substantially with
provision for the non-allopathic systems of medicine as well as for allopathy.
Beneficiaries at this moment are around 432 000, spread across 22 cities. The CGHS has
been criticized from the point of view of quality and accessibility. Subscribers have
complained of high out-of-pocket expenses due to slow reimbursement and incomplete
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).

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 protection to employees
against loss of wages due to inability to work due to sickness, maternity, disability 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 non-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 papers 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 125 hospitals, 42 annexes and 1 450
dispensaries with over 23 000 beds facilities. The scheme is managed and financed by the
Employees State Insurance Corporation (a public undertaking) through the state
governments, with total expenditure of Rs 3 300 million or Rs 400/- per capita insured
person.The ESIS programme 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 quality drugs, long waiting periods, impudent behaviour of
personnel, lack of interest or low interest on part of employees and low awareness of ESI
procedures, were some of the reasons cited.
Other Government Initiatives
Apart from the government-run schemes, social security benefits for the disadvantaged
groups can be availed of, under the provisions of the Maternity Benefit (Amendment) Act
1995, Workmen’s Compensation (Amendment) Act 1984, Plantation Labour Act 1951,
Mine Mines Labour Welfare Fund Act 1946, Beedi Workers Welfare Fund Act 1976 and
Building and other Construction Workers (Regulation of Employment and Conditions of
Service) Act, 1996. The Government of India has also undertaken initiatives to address
issues relating to access to public health systems especially for the vulnerable sections of
the society. The National Health Policy 2002 acknowledges this and aims to evolve a
policy structure, which reduces such inequities and allows the disadvantaged sections of
the population a fairer access to public health services. Ensuring more equitable access to
health services across the social and geographical expanse of the country is the main
objective of the policy. It also seeks to increase the aggregate public health investment
through increased contribution from the Central as well as state governments and
encourages the setting up of private insurance instruments for increasing the scope of
coverage of the secondary and tertiary sector under private health insurance packages.
The government envisages an increase in health expenditure as a % of GDP from existing
0.9% to 2.0 % by 2010 and an increase in the share of central grants from the existing
15% to constitute at least 25% of total public health spending by 2010. The State
government spending for health in turn would increase from 5.5% to 7% of the budget by
2005, to be further increased to 8% by 2010. The National Population Policy (NPP) 2000,
envisages the establishment of a family welfare-linked health insurance plan. As per this
plan, couples living below the poverty line who undergo sterilization with not more than
two living children would be eligible for insurance. Under this scheme, the couple along
with their children would be covered for hospitalization not exceeding Rs 5 000 and a
personal accident insurance cover for the spouse undergoing sterilization. The Institute of
Health Systems (IHS), Hyderabad has been entrusted the responsibility of
operationalizing the mandate of the NPP 2000. The initial scheme proposed by the HIS
was discussed at a workshop in June 2003. The consensus at the meeting was that the
scheme, needed further improvement prior to its implementation even as a pilot project.
In keeping with the recommendations of the Tenth Five Year Plan and the National
Health Policy (NHP) 2002, the Department of Family Welfare is also proposing to
commission studies in eight states covering eight districts, to generate district-specific
data, which is essential for conceptualization of a reasonable and financially viable
insurance scheme. The current plan – the Tenth Five Year Plan (2002-07) - also focuses
on exploring alternative systems of health care financing including health insurance so
that essential, need-based and affordable health care is available to all. The urgent need to
evolve, implement and evaluate an appropriate scheme for health financing for different
income groups is acknowledged. In the past, the government has tried to ensure that the
poor get access to private health facilities through subsidy in the form of duty exemptions
and other such benefits. Social health insurance for families living below the poverty line
has been suggested as a mechanism for reducing the adverse economic consequences of
hospitalization and treatment for chronic ailments requiring expensive and continuous
care. In the budget for the year 2002-2003, an insurance scheme called Janraskha was
introduced, with the aim of providing protection to the needy population. With a
premium of Re 1/- per day, it ensured indoor treatment up to Rs 3 000 per year at selected
and designated hospitals and outpatient treatment up to Rs 2 000 per year at designated
clinics, including civil hospitals, medical colleges, private trust hospitals and other NGO-
run institutions. A few states have started implementing this scheme under pilot phase. In
the budget for the period 2003-2004, another initiative of community-based health
insurance has been announced. This scheme aims to enable easy access of less
advantaged citizens to good health services, and to offer health protection to them. This
policy covers people between the age of three months to 65 years. Under this scheme, a
premium equivalent to Re 1 per day (or Rs 365 per year) for an individual, Rs 1.50 per
day for a family of five (or Rs 548 per year), and Rs 2 per day for a family of seven (or
Rs 730 per year), would entitle them to get reimbursement of medical expenses up to
Rs 30 000 towards hospitalization, a cover for death due to accident for Rs 25000 and
compensation due to loss of earning at the rate of Rs 50 per day up to a maximum of 15
days. The government would contribute Rs 100 per year towards the annual premium, so
as to ensure the affordability of the scheme to families living below the poverty line. The
implementation of this scheme rests with the four public sector insurance companies.
The government also offers assistance by way of Illness Assistance Funds, which have
been set up by the Ministry of Health and Family Welfare at the national level and in a
few states. State Illness Assistance Funds exist in Andhra Pradesh, Bihar, Goa, Gujarat,
Himachal Pradesh, Jammu and Kashmir, Karnataka, Kerala, Madhya Pradesh,
Maharashtra, Mizoram, Rajasthan, Sikkim, Tamil Nadu, Tripura, West Bengal, NCT of
Delhi and UT of Pondicherry. A National Illness Assistance Fund (NIAF) was set up in
1997, with the scheme being reviewed in January 1998. Through this, three Central
Government hospitals and three national-level institutes have been sanctioned Rs 10 00
000 each at a time from the NIAF to provide immediate financial assistance to the extent
of Rs 25 000 per case to poor patients living below the poverty line and who are
undergoing treatment in these hospitals / institutions. Thereafter the scheme has been
extended to few other institutes across the country and provides Rs 25 000 – Rs 50 000
per case.
Health insurance initiatives by State Governments
In the recent past, various state governments have begun health insurance initiatives. For
instance, the Andhra Pradesh government is implementing the Aarogya Raksha Scheme
since 2000, with a view to increase the utilization of permanent methods of family
planning by covering the health risks of the acceptors. All people living below the
poverty line and those who accept permanent methods of family planning are eligible to
be covered under this scheme. The Government of Andhra Pradesh pays a premium of Rs
75 per acceptor. The benefits to be availed of, include hospitalization costs up to Rs. 4000
per year for the acceptor and for his / her two children for a total period of five years
from date of the family planning operation. The coverage is for common illnesses and
accident insurance benefits are also offered. The hospital bill is directly reimbursed by
the Insurance Company, namely the New India Assurance Company. The Government of
Goa along with the New India Assurance Company in 1988 developed a medical
reimbursement mechanism. This scheme can be availed by all permanent residents of
Goa with an income below Rs 50 000 per annum for hospitalization care, which is not
available within the government system. The non-availability of services requires
certification from the hospital Dean or Director Health Services. The overall limit is
Rs 30 000for the insured person for a period of one year. A pilot project on health
insurance was launched by the Government of Karnataka and the UNDP in two blocks
since October 2002. The aim of the project was to develop and test a model of
community health financing suited for rural community, thereby increasing the access to
medical care of the poor. The beneficiaries include the entire population of these blocks.
The premium is Rs 30 per person per year, with the Government of Karnataka
subsidizing the premium of those below poverty line and those belonging to Scheduled
Castes/ Scheduled Tribes. This premium entitles them to hospitalization coverage in the
government hospitals up to a maximum of Rs 2500 per year, including hospitalization for
common illnesses, ambulance charges, loss of wages at Rs. 50 per day as well as drug
expenses at Rs 50 per day. Reimbursements are made to an insurance fund which has
been set up by the NGO / PRI with the support of UNDP.

The Government of Kerala is planning to launch a pilot project of health insurance for the
30% families living below the poverty line. The scheme would be associated with a
government insurance company. Currently, negotiations are under way with the
 IRA to seek service tax exemption. The proposed premium is Rs 250 plus 5% tax.
The maximum benefit per family would be Rs 20 000. The amount for the premium
would be recovered from the drug budget (Rs 100), the PRI (Rs 100) and from the
beneficiary (Rs 62.50) while the benefits available would include cover for
hospitalization, deliveries involving surgical procedures (either to the mother or the
newborn). Instead of payment by the beneficiary, Smart Card facility would be
offered. This scheme would be applicable in 216 government hospitals.

6. Comparison:-

Australia

The public health system is called Medicare. It ensures free universal access to hospital
treatment and subsidized out-of-hospital medical treatment. It is funded by a 1.5%
tax levy.The private health system is funded by a number of private health
insurance organizations. The largest of these is Medibank Private, which is
government-owned, but operates as a government business enterprise under the
same regulatory regime as all other registered private health funds. The Coalition
Howard government had announced that Medibank would be privatised if it won
the 2007 election, however they were defeated by the Australian Labor Party
under Kevin Rudd which had already pledged that it would remain in
government ownership.Some private health insurers are 'for profit' enterprises,
and some are non-profit organizations such as HCF Health Insurance. Some
have membership restricted to particular groups, but the majorities have open
membership.Most aspects of private health insurance in Australia are regulated by
the Private Health Insurance Act 2007.The private health system in Australia
operates on a "community rating" basis, whereby premiums do not vary solely
because of a person's previous medical history, current state of health, or
(generally speaking) their age (but see Lifetime Health Cover below). Balancing
this are waiting periods, in particular for pre-existing conditions (usually referred
to within the industry as PEA, which stands for "pre-existing ailment"). Funds are
entitled to impose a waiting period of up to 12 months on benefits for any medical
condition the signs and symptoms of which existed during the six months ending
on the day the person first took out insurance. They are also entitled to impose a
12-month waiting period for benefits for treatment relating to an obstetric
condition, and a 2-month waiting period for all other benefits when a person first
takes out private insurance. Funds have the discretion to reduce or remove such
waiting periods in individual cases. They are also free not to impose them to
begin with, but this would place such a fund at risk of "adverse selection",
attracting a disproportionate number of members from other funds, or from the
pool of intending members who might otherwise have joined other funds. It
would also attract people with existing medical conditions, who might not
otherwise have taken out insurance at all because of the denial of benefits for 12
months due to the PEA Rule. The benefits paid out for these conditions would
create pressure on premiums for all the fund's members, causing some to drop
their membership, which would lead to further rises, and a vicious cycle would
 ensue.There are a number of other matters about which funds are not permitted to
discriminate between members in terms of premiums, benefits or membership -
these include racial origin, religion, sex, sexual orientation, nature of
employment, and leisure activities. Premiums for a fund's product that is sold in
more than one state can vary from state to state, but not within the same state.

The Australian government has introduced a number of incentives to encourage adults to

take out private hospital insurance. These include:

• Lifetime Health Cover: If a person has not taken out private hospital cover by
the 1st July after their 30th birthday, then when (and if) they do so after this time,
their premiums must include a loading of 2% per annum. Thus, a person taking
out private cover for the first time at age 40 will pay a 20 per cent loading. The
loading continues for 10 years. The loading applies only to premiums for hospital
cover, not to ancillary (extras) cover.

• Medicare Levy Surcharge: People whose taxable income is greater than a

specified amount (currently $70,000 for singles and $140,000 for couples) and
who do not have an adequate level of private hospital cover must pay a 1%
surcharge on top of the standard 1.5% Medicare Levy. The rationale is that if the
people in this income group are forced to pay more money one way or another,
most would choose to purchase hospital insurance with it, with the possibility of a
benefit in the event that they need private hospital treatment - rather than pay it in
the form of extra tax as well as having to meet their own private hospital costs.
The Australian government announced in May 2008 that it proposes to increase
the thresholds, to $100,000 for singles and $150,000 for families. These changes
require legislative approval. A bill to change the law has been introduced but was
not passed by the Senate. A changed version was passed on 16 October 2008.
There have been criticisms that the changes will cause many people to drop their
private health insurance, causing a further burden on the public hospital system,
and a rise in premiums for those who stay with the private system. Other
commentators believe the effect will be minimal.

• Private Health Insurance Rebate: The government subsidizes the premiums for
all private health insurance cover, including hospital and ancillary (extras), by
30%, 35% or 40%.

Canada

Most health insurance in Canada is administered by each province, under the Canada
Health Act, which requires all people to have free access to basic health services.
Collectively, the public provincial health insurance systems in Canada are
frequently referred to as Medicare. Private health insurance is allowed, but the
provincial governments allow it only for services that the public health plans do
not cover; for example, semi-private or private rooms in hospitals and prescription
drug plans. Canadians are free to use private insurance for elective medical
 services such as laser vision correction surgery, cosmetic surgery, and other non-
basic medical procedures. Some 65% of Canadians have some form of
supplementary private health insurance; many of them receive it through their
employers. Private-sector services not paid for by the government account for
nearly 30 percent of total health care spending.

In 2005, the Supreme Court of Quebec ruled, in Chaoulli v. Quebec, that the province's
prohibition on private insurance for health care already insured by the provincial plan
could constitute an infringement of the right to life and security if there were long wait
times for treatment as happened in this case. Certain other provinces have legislation
which financially discourages but does not forbid private health insurance in areas
covered by the public plans. The ruling has not changed the overall pattern of health
insurance across Canada but has spurred on attempts to tackle the core issues of supply
and demand and the impact of wait times.

France

The French model of health insurance has been ranked by the World Health Organisation
as the best in the world, because it permits a high quality of care and nearly total patient
freedom. The national system of health insurance was instituted in 1945, just after the end
of the Second World War. It was a compromise between Gaullist and Communist
representatives in the French parliament. The Conservative Gaullists were opposed to a
state-run healthcare system, while the Communists were supportive of a complete
nationalisation of health care along a British Beveridge model. The resulting programme
was profession-based : all people working were required to pay a portion of their income
to a health insurance fund, which mutualised the risk of illness, and which reimbursed
medical expenses at varying rates. Children and spouses of insured people were eligible
for benefits, as well. Each fund was free to manage its own budget and reimburse medical
expenses at the rate it saw fit.

The government has two responsibilities in this system.

• The first government responsibility is the fixing of the rate at which medical
expenses should be negotiated, and it does this in two ways: The Ministry of
Health directly negotiates prices of medicine with the manufacturers, based on the
average price of sale observed in neighboring countries. A board of doctors and
experts decides if the medicine provides a valuable enough medical benefit to be
reimbursed (note that most medicine is reimbursed, including homeopathy). In
parallel, the government fixes the reimbursement rate for medical services : this
means that a doctor is free to charge the fee that he wishes for a consultation or an
examination, but the social security system will only reimburse it at a pre-set rate.
These tariffs are set annually through negotiation with doctors' representative
organisations.
• The second government responsibility is oversight of the health-insurance funds,
to ensure that they are correctly managing the sums they receive, and to ensure
oversight of the public hospital network.
Today, this system is more-or-less intact. All citizens and legal foreign residents of
France are covered by one of these mandatory programs, which continue to be funded by
worker participation. However, since 1945, a number of major changes have been
introduced. Firstly, the different health-care funds (there are five : General, Independent,
Agricultural, Student, Public Servants) now all reimburse at the same rate. Secondly,
since 2000, the government now provides health care to those who are not covered by a
mandatory regime (those who have never worked and who are not students, meaning the
very rich or the very poor). This regime, unlike the worker-financed ones, is financed via
general taxation and reimburses at a higher rate than the profession-based system for
those who cannot afford to make up the difference. Finally, to counter the rise in health-
care costs, the government has installed two plans, (in 2004 and 2006), which require
insured people to declare a referring doctor in order to be fully reimbursed for specialist
visits, and which installed a mandatory co-pay of 1 € (about $1.45) for a doctor visit, 0,50
€ (about 80 ¢) for each box of medicine prescribed, and a fee of 16-18 € (20-25 $) per
day for hospital stays and for expensive procedures.

An important element of the French insurance system is solidarity : the more ill a person
becomes, the less they pay. This means that for people with serious or chronic illnesses,
the insurance system reimburses them 100 % of expenses, and waives their co-pay
charges.

Finally, for fees that the mandatory system does not cover, there is a large range of
private complementary insurance plans available. The market for these programs is very
competitive, and often subsidised by the employer, which means that premiums are
usually modest. 85% of French people benefit from complementary private health
insurance.

Netherlands

In 2006, a new system of health insurance came into force in the Netherlands. This new
system avoids the two pitfalls of adverse selection and moral hazard associated with
traditional forms of health insurance by using a combination of regulation and an
insurance equalization pool. Moral hazard is avoided by mandating that insurance
companies provide at least one policy which meets a government set minimum standard
level of coverage, and all adult residents are obliged by law to purchase this coverage
from an insurance company of their choice. All insurance companies receive funds from
the equalization pool to help cover the cost of this government-mandated coverage. This
pool is run by a regulator which collects salary-based contributions from employers,
which make up about 50% of all health care funding, and funding from the government to
cover people who cannot afford health care, which makes up an additional 5%. The
remaining 45% of health care funding comes from insurance premiums paid by the
public, for which companies compete on price, though the variation between the various
competing insurers is only about 5%. However, insurance companies are free to sell
additional policies to provide coverage beyond the national minimum. These policies do
not receive funding from the equalization pool, but cover additional treatments, such as
dental procedures and physiotherapy, which are not paid for by the mandatory policy.
Funding from the equalization pool is distributed to insurance companies for each person
they insure under the required policy. However, high-risk individuals get more from the
pool, and low-income persons and children under 18 have their insurance paid for
entirely. Because of this, insurance companies no longer find insuring high risk
individuals an unappealing proposition, avoiding the potential problem of adverse
selection.

Insurance companies are not allowed to have co-payments, caps, or deductibles, or to

deny coverage to any person applying for a policy, or to charge anything other than their
nationally set and published standard premiums. Therefore, every person buying
insurance will pay the same price as everyone else buying the same policy, and every
person will get at least the minimum level of coverage.

United Kingdom

The UK's National Health Service (NHS) is a publicly funded healthcare system that
provides coverage to everyone normally resident in the UK. It is not strictly an insurance
system because (a) there are no premiums collected, (b) costs are not charged at the
patient level and (c) costs are not pre-paid from a pool. However, it does achieve the
main aim of insurance which is to spread financial risk arising from ill-health. The costs
of running the NHS (est. £104 billion in 2007-8)[28] are met directly from general
taxation. The NHS provides the majority of health care in the UK, including primary
care, in-patient care, long-term health care, ophthalmology and dentistry.

Private health care has continued parallel to the NHS, paid for largely by private
insurance, but it is used by less than 8% of the population, and generally as a top-up to
NHS services. There are many treatments that the private sector does not provide. For
example, health insurance on pregnancy is generally not covered or covered with
restricting clauses.[29] One of the major insurers, BUPA, excludes many forms of
treatment and care that most people will need during their lifetime or specialist care most
of which are freely available from the NHS. These include:- ageing, menopause and
puberty; AIDS/HIV; allergies or allergic disorders; birth control, conception, sexual
problems and sex changes; chronic conditions; complications from excluded or restricted
conditions/ treatment; convalescence, rehabilitation and general nursing care ; cosmetic,
reconstructive or weight loss treatment; deafness; dental/oral treatment (such as fillings,
gum disease, jaw shrinkage, etc); dialysis; drugs and dressings for out-patient or take-
home use† ; experimental drugs and treatment; eyesight; HRT and bone densitometry;
learning difficulties, behavioural and developmental problems; overseas treatment and
repatriation; physical aids and devices; pre-existing or special conditions; pregnancy and
childbirth; screening and preventive treatment; sleep problems and disorders; speech
disorders; temporary relief of symptoms († = except in exceptional circumstances)

Recently the private sector has been used to increase NHS capacity despite a large
proportion of the British public opposing such involvement. According to the World
Health Organization, government funding covered 86% of overall health care
expenditures in the UK as of 2004, with private expenditures covering the remaining
14%.

United States

The US market-based health care system relies heavily on private and not-for-profit
health insurance, which is the primary source of coverage for most Americans. According
to the United States Census Bureau, approximately 84% of Americans have health
insurance; some 60% obtain it through an employer, while about 9% purchase it directly.
Various government agencies provide coverage to about 27% of Americans (there is
some overlap in these figures).

Public programs provide the primary source of coverage for most seniors and for low-
income children and families who meet certain eligibility requirements. The primary
public programs are Medicare, a federal social insurance program for seniors and certain
disabled individuals, Medicaid, funded jointly by the federal government and states but
administered at the state level, which covers certain very low income children and their
families, and SCHIP, also a federal-state partnership that serves certain children and
families who do not qualify for Medicaid but who cannot afford private coverage. Other
public programs include military health benefits provided through TRICARE and the
Veterans Health Administration and benefits provided through the Indian Health Service.
Some states have additional programs for low-income individuals.

In 2006, there were 47 million people in the United States (16% of the population) who
were without health insurance for at least part of that year. About 37% of the uninsured
live in households with an income over $50,000.[

In 2004, US health insurers directly employed almost 470,000 people at an average salary
of $61,409. (As of the fourth quarter of 2007, the total US labor force stood at 153.6
million, of whom 146.3 million were employed. Employment related to all forms of
insurance totaled 2.3 million. Mean annual earnings for full-time civilian workers as of
June 2006 were $41,231; median earnings were $33,634.) The insurance industry also
represents a significant lobbying group in the US. For 2008 insurance was the 8th among
industries in political contributions to members of Congress, giving $28,654,121, of
which 51% was given to Democrats and 49% to Republicans, with the top recipient of
insurance industry contributions being Senator John McCain (R-AZ). The leading
contributor from the insurance industry — as measured by total political contributions —
was AFLAC, Inc., which contributed $907,150 in 2007.

7. Conclusions:-
There are few issues of concern or barriers towards implementing a social health
insurance scheme in India. These are enumerated below along with the possible way
ahead. India is a low-income country with 26% population living below the poverty line,
and 35% illiterate population with skewed health risks. Insurance is limited to only a
small proportion of people in the organized sector covering less than 10% of the total
population. Currently, there no mechanism or infrastructure for collecting mandatory
premium among the large informal sector. Even in terms of the existing schemes, there is
insufficient and inadequate information about the various schemes. Data gaps also
prevail. Much of the focus of the existing schemes is on hospital expenses. There
continues to be lack of awareness among people about health insurance. In spite of
existing regulation in some States, the private sector continues to operate in an almost
unhindered manner. The growth of health insurance increases the need for licensing and
regulating private health providers and developing specific criteria to decide upon
appropriate services and fees. Health insurance per se, suffers from problems like adverse
selection, moral hazard, cream-skimming and high administrative costs. This is coupled
with the fact that in the absence of any costing mechanisms, there is difficulty in
calculating the premium. There is also a need to evolve criteria to be used for deciding
upon target groups, who would avail of the SHI scheme/s and also to address issues
relating to whether indirect costs would be included in health insurance. Health insurance
can improve access to good quality health care only if it is able to provide for health care
institutions with adequate facilities and skilled personnel at affordable cost. Given this
scenario, the challenge, then, for 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 delivery
system and explores other social security options like health insurance. Implementing
regulations would be one, but by no means the best mechanism to contain 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 undertake 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 burden at various
geographical regions; to develop standard treatment guidelines, to undertake 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 of all 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.
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