A

Presentation
on

Health Insurance

By

D.Pradeep Kumar
Exe-MBA IIPM, Hyderabad
INDIA

Total Area :3 million sq.km

No. of Provinces : 29
Union Territories : 6
Coastal line : 6,700 km
The Human Being will live longer
..but not necessarily healthier

Life Expectancy in India

Year 1955 2005 2025
Age
48 64 75*
(in Years)

*Source: The OASIS (Old Age Social and Income Security committee report)
The Human Being will live longer
…but not necessarily work longer

Age 18 to 60 Age 60 to 67

Previous
Working – 42 yrs Retirement – 7 yrs generation

Age 25 to 55 Age 55 to 75

Working – 30 years Retirement – 20 years Today

Life stage of average individual

 INTRODUCTION

• Health insurance is insurance that pays

for medical expenses. It is sometimes used
more broadly to include insurance covering
disability or long-term nursing or custodial
care needs
Why Do I Need Insurance?

• Healthcare can be expensive!

– Experts believe that medical bills are a factor in
one out of five bankruptcies (MSNMoney.com)

• In the chance that you or your family gets ill, you

want to be protected against possible financial
hardships
 New IRDA Guidelines
* A Health Insurance company cannot refuse to renew policy, except in cases of fraud,
which means a wrongful claim has been made to dupe the insurance company.

* Just because you have been hospitalized for an illness, and when you go back for
renewal the Insuring company cannot force you to move to another plan. They will
have to renew the one you already have.

* A lot of insurers are very unclear in their document about renewable dates and
options. Now, those Disclosures will have to be made upfront. Also, right now,1 to 2
day delay in paying your premium and kaboom! There goes your medical insurance
policy. They simply refuse to renew it. Now, they will have to give a 15 days grace
period to renew policy. These new IRDA standards come into effect from June 1st
2009.
• * You can Tag premium paying dates to important events like
birthdays or say before Christmas or before the summer
holidays.
 Cont….!
* One of the biggest areas of dispute between insurance companies and
policy holders has been in dealing with pre-existing diseases. Now all
companies will have to insure pre-existing diseases after 5 years of
holding the policy, though what exactly is pre-existing, IRDA yet has to
define.
We all know that a mediclaim policy means
the hospital bills will get paid. But there is
lots more to know so that we maximise this
insurance…..!
• A 30 day waiting period for claim on a new policy

• Rs 5 lakh cap on most covers

• Sub limits on room rent and procedure expenses

• 24 hour hospitalisation rule gets waived for eye surgery, dialysis, kidney stone removal.

• Expenses 30 days before and 60 days after are part of the pay-out

* Exclusions - dental, pregnancy, OPD, alternative medicine, psychiatric disorders, cosmetic

surgery.

* Pre-existing diseases don't get immediate cover, but

only after 5 claim free years
 When should I get signed up……?

• Now….!

• There is no better time to get signed up for

health insurance
• You never know when you will need medical
coverage; these things are very unpredictable,
and it is best to have coverage in case you need it.
Types of Health Insurance
• Health Maintenance Organization (HMO)
– Must choose a Primary Care Physician (PCP)
– Need to have a referral to see a specialist
– Typically do not have deductibles and co-pays
are nominal amounts

• Preferred Provider Organization (PPO)

– No PCP is necessary
– Can refer oneself to a specialist
– Usually higher deductibles and co-pays

• High-deductible PPO
– Catastrophic coverage
– Low premiums but high deductibles
 Health Insurance Company’s….!
• Tata AIG
• HDFC Chubb
• Bajaj Allianz 
• ICICI Lombard
• IFFCO Tokio
• Royal Sundaram
• Oriental Insurance
• Cholaman-dalam
• New India Assurance
• United India Insurance
• National Insurance
Presenting a new health plan.

Trust us,
your customer will thank
you for it!
Presenting

That covers you today

and invests your
money for tomorrow
 Yes, the customer will need a health plan
…but not necessarily the one You have in mind

A plan which:

Provides guaranteed reimbursement

hospitalization cover till age 75

Builds up a health fund and allows

claims for health expenses not covered in
the hospitalization cover

Flexibility in premium payment

Gives complete tax benefit under Section

80D
 How does the plan work?
Select the annual limit for the hospitalization cover

Select a suitable premium

Basis age and annual limit chosen, part of premium will go towards the
health cover and remaining invested to build a health fund*

Hospitalisation Insurance Health Savings

Benefit Benefit

To cover you against To cover you against all other

hospitalization expenses health expenses

*Invested premiums mean premiums post deduction of

applicable charges
 The features in detail
Hospitalisation
Health Savings Benefit
Insurance Benefit

Guaranteed coverage No re-evaluation of health status or refusal of cover during

till age 75 term

No addition of exclusions or increase in premiums due to

claims made

No claims Bonus A bonus of 5% on annual limit added for every claim free
year

Bonus amount up to 25% can be added

Cover yourself, spouse and upto 3 dependant children under

Family floater same plan
 The features in detail
Hospitalisation
Health Savings Benefit
Insurance Benefit

A free health check-up once every 2 policy years after the

Free Health Checkup first year

Reimbursement of amount up to 1% of annual limit or Rs

5000 whichever is lower.

Pre-Existing illnesses Pre-existing illnesses covered after 2 years

Cover
The disease to be declared at inception & accepted by the
company

Cashless
Cashless claims settlement in over 5000 network hospitals
Hospitalization
 Health Saver charges
• Health Insurance Charges:
Annual Limit 25 yrs 35 yrs 45 yrs 55 yrs
2 Lacs 2337 2756 3564 7052
3 lacs 2693 3179 3928 7836

5 lacs 2881 3402 4203 8384

7 lacs 3069 3624 4476 8929

10 lacs 3283 3878 4790 9554

Inclusive of ST & Education Cess

• The health insurance charges are valid from 1 year of policy commencement
date and are subject to change post IRDA approval
 The Health Saver advantage: The most
comprehensive coverage
Benefits Health Traditiona
Saver l Comprehensive coverage
Mediclai against both inpatient and
m outpatient medical instances
Hospitalisation  
Coverage Pays for any kind of medical
Daycare Procedures   expense incurred during the
OPD expenses   policy term
Maternity expenses  

Dental treatment  
Medical equipment  
expenses
Day to day  
medicines & drugs
expenditure
 The claims process –
hospitalization insurance benefit
HOSPITALISATION

Network Hospital Non-Network Hospital

Planned Emergency Customer settle bill with

Hospital

Submit Preauthorization Form

Post discharge,
submit claim form
Scrutiny
Pre(30)&Post(60)
Scrutiny
Hospitalization*
Cashless not
Cashless authorized
authorized
Cheque sent
Reject
Customer signs to Customer
Documents on
Discharge
•Reimbursed only in the Event of
acceptance of the Hospitalisation or Day
ICICI pays Hospital Care Procedures claim by the Company.
•TAT -3hrs
 Things to Note….!

• Eldest member is the “primary life”

• Individual underwriting questions for each family
member
• DOB proofs required for all members
• Signature for all members
 Bottom Line….?

 SOMETHING IS BETTER THAN NOTHING!

 This is your health; it is not a trivial matter

 Health insurance is necessary!

 Sources

• www.ndtvprofit.com
• www.Wikipedia.com
• www.insureurhealth.com
• www.healthinsuranceindia.org
• www.iciciprudential.com
Thank You