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Private Health Insurance
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Private Health InsuranceSchemes(PHI)
Schemes ofered by the insurancecompanies in the open market
Enrolment is voluntary and not determinedby legislation
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Public sector Health Insurance Companies
General Insurance Corporation (GIC) throughits !our subsidiaries is the largest player
"e# India $ssurance Company
"ational Insurance Company
%nited India Insurance Company &td'
riental Insurance Company &td'
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Private sector Health Insurance Companiesin India
harti $*a Health Ins'
ICICI &ombard
I++C ,okyo
-eliance General Ins'
-oyal Sundaram
SI General Insurance
Shriram General Ins'
Cholamandalam GeneralInsurance
-ahe.a /E Genaral Ins'
$pollo 0unich Health Ins
0a* upa Health Ins' -eligare Health Ins'
Star Health 1 $llied Ins'
H2+C E-G General Ins'
0agma H2I Insurance
+uture Generalis India Insurance
&iberty 3ideocon General InsuranceCo' &td'
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0arket based systems4policies on ofer
Individual
+amily +loaterCritical Illness
Senior Citi5en
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A.Individual health plan/ Mediclaim:
. ,raditional health insurance covers commonlykno#n as 60ediclaim6 policies'
.Covering about 7'8 million o! population 0ediclaim
is one o! the oldest 1 most popular healthinsurance plans'
. ,he government insurance companies started 9rsthealth insurance in :; hours'
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InclusionsA ,he e*penses !or hospital bed
"ursing
Surgeon6s !ees
Consultant doctor6s !eesCost o! blood 4o*ygen and
peration theatre charges
E*clusionsAutpatient treatments'
PreBe*isting diseases or complications arising !romthem !or the 9rst !our years o! the policy'
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InclusionsAHospitali5ation e*penses
2ay care treatment
$mbulance charges
Pre e*isting diseases a!ter t#o4!our years
Some policies cover $D%SH treatment up tospeci9ed limits
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Exclusions
2iseases contracted #ithin ?@ days o!insurance
2ental treatment
2ebility 1 general rundo#n conditions
S,2 $I2SCosmetic surgery plastic surgery
3accination
2omiciliary treatment
Pregnancy and childbirth
"aturopathy
ar "uclear #eapons
,reatment outside India
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C. Critical Illness PlanA It provides 9nancialassistance i! the insured develops a seriousailment such as cancer or has a stroke'
. !enior citi"ens health planAB 0ostIndividual Health plans cap the entry age ataround =@ years #hile Senior Citi5en HealthPlans are generally !or the age group o! =@B
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IllustrationA ICICI &ombard
Comprehensive coverage !or individual and!amily
+le*ibility to choose !rom a #ide range o!
options on sum insured premium and plansGuaranteed li!elong rene#ability
"o restriction on ma*imum age rene#ability
Pree*isting illness covered a!ter t#o4!our years
Choice o! add on covers available
"o copayments
"o health check up to the age o! >8 years
ouFuet o! value added services
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ey +eatures o! PHI
0emberA Consumer .oining the insurance !und
,PIA Institution responsible !or managing the!und
Cover4 Provision4 ene9t4 EntitlementA hatmember can receive !rom insurance !und'
PremiumA -egular payments made by theconsumer
$dverse selectionA ,he insurers #ant to deter ore*clude those #ho are at high risk i'e those mostin need o! healthcare and to have as many lo#Brisk members as possible' Ho#ever the bestrisks select themselves out o! the insured group'
Hence insurance companies ofer diferent
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Process
Pays premium Pays to#ards costo! services
Provides health services
,hird Part InstitutionsGovernment or
Private (!or pro9t ornonBpro9t)
0anaging paymentsin a !und !or
consumers
Health Care ProviderGovernment or
Private (!or pro9t ornonBpro9t) providing
health care andreceiving payment
!rom third partyinstitutions
Consumer individual
and or employermaking regular
payments to a !undand receiving
bene9ts
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,P$ means a ,hird Party $dministrator#ho !or the time being is licensed by the$uthority and is engaged !or a !ee orremuneration by #hatever name called asmay be speci9ed in the agreement #ith aninsurance company !or the provision o!health services
Presently ?: ,P$s are registered #ith I-2$
&icenses are valid !or a period o! three years!rom date o! issue
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BUSINESSMODEL
INSURER
T.PA.
Provider Corporate/Individual
P o l i
c y
P r e m i u
m
S e r v
i c e s
Business
Services
S e r v
i c e s
B u s i n e s s
C l a
i m
M n
g t .
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Pre-authorization
Enrollment
ID Car
!" hrs #el$-line
Toll %ree
MIS
Claims
management
&e' access
Personalize
Client Service(et)or* #os$itals
Cashless
T.P.A
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TPA Functions
ene9ts 0anagement 4 Claim Settlement
Provider "et#ork 0anagement 4
0aintaining 2atabase
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Claim settlement / Bene#tsMana$ement:
,aking intimation o! claim
$dvising customers on net#ork hospitals
$pproving cashless and reimbursement claims
2isbursing the claim to the customersPlan 2esignEnrolment ProcessingPhoto I2 CardStandard +orms7>B Hour Call Centre ( Help 2esk)+und 0anagement
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Call Centre: edicated mem%er helpline &' x(
)ation*ide +oll ,ree num%er 7> J Kdays accessible
Electronically supported systems0anaged by pro!essionally skilled manpo#er $ssistance in in!ormation on "et#ork hospitals
Enrollment status Support services in an Emergency Coverage eligibility ClaimsB documentation support Fuery
handling
General in!ormation on health plan
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Provider )et*or- Mana$ement/ Maintainin$ata%ase
0aintaining all records o! customers
Issuing identity cards to all policyholders-un 7> hour toll !ree number
Have !ull time medical practitioners to takedecision as to #hether ailment is covered under
the policyE*pansion o! "et#ork
Cashless PreB authori5ation 0anagement
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alue added servicesA$rranging ambulance services
0edicines and supplies
Guiding policy holders !or specialistconsultation
Providing in!ormation about health!acilities bed availability organi5ation o!
li!estyle management and #ell beingprogrammes
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Eligibility
Covered
Not
Covered
Preauthori"ationProcess ,or Cashless
Hospital sends
Intimation to TPA
Authorization as per eligibility
Out of Pocket
payment
Member
approaches
with Hospitals
mp! I"
Cashless treatment
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TPA processes claimsSettle the Claim
TPA representative verifies the documents submitted
In case of incomplete documentsrecovery of documents for
scrutiny
Member avails treatment at any hospital and makesupfront payment
Member submits bills toTPA Help desk
Protocol ,or Availin$ +reatment in )on )et*or-
Hospital
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Member ReimbursementClaim (MRC)
CompleteDocuments
IncompleteDocuments
Network Hospital Claim
At TPA – Document verification
Settlement / Rejection
Claims Management
At TPA ClaimsProcessing / Medical scrutiny Receipt of missing document
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Insurance claim settlement
$ll reimbursement claims must be submitted #ithin ?@days o! discharge
ocuments to %e veri#ed:
2ischarge card&etter o! 9rst consultation and advice !or hospitali5ation
Hospital bills #ith receipts
0edicine bills #ith doctor prescription
0edical reports bill receipts and doctors letter !ortests
Consultation receipts
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I-2$
Insurance -egulatory and 2evelopment$uthority (I-2$) is an autonomous ape*statutory body #hich regulates and develops
the insurance industry in India'Constituted by an act o! Parliament in :;;;
HeadFuaters in 2elhi
I-2$ $ct allo#s the private players to enter the
insurance sector in India'I-2$ approved services o! ,P$Ls as Insurance
intermediaries (7@@:)
I-2$ serves to protect the interests o! holders
o! insurance policies to regulate promote andensure orderly gro#th o! the insurance industry
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I-2$ provides registration certi9cate toinsurance companies and responsible !orrene#al modi9cation cancellation andsuspension o! the registration certi9cate
I-2$ is a :@ member body having a chairman9ve #hole time and !our part time membersall appointed by the Govt' o! India