The document provides an overview of health insurance in India. It defines health insurance and describes what a typical health insurance policy covers, including room and boarding expenses, nursing costs, surgeon fees, and medical treatment costs. It notes that over 80% of Indians lack health insurance coverage. The major types of health insurance policies in India include hospitalization plans, pre-existing disease plans, senior citizen plans, maternity plans, daily cash plans, and critical illness plans. The document also outlines several government-run health insurance schemes in India like RSBY, Ayushman Bharat, and state-specific programs. It concludes with a discussion of public and private agencies involved in providing health insurance in India.

1. HEALTH
INSURANCE

2. WHAT IS HEALTH INSURANCE
 Health Insurance is defined as "coverage that provides
for the payments of benefits as a result of sickness or
injury. It includes insurance for losses from accident,
medical expense, disability, or accidental death and
dismemberment“
 A health insurance policy like other policies is a
contract between an insurer and an individual / group
in which the insurer agrees to provide specified health
insurance cover at a particular “premium” subject to
terms and conditions specified in the policy.

3. WHAT A HEALTH INSURANCE POLICY WOULD
NORMALLY COVER?
 A Health Insurance Policy would normally cover expenses
reasonably and necessarily incurred under the following
heads in respect of each insured person subject to overall
ceiling of sum insured (for all claims during one policy
period).
a) Room, Boarding expenses
b) Nursing expenses
c) Fees of surgeon, anesthetist, physician, consultants,
specialists
d) Anesthesia, blood, oxygen, operation theatre charges,
surgical appliances, medicines, drugs, diagnostic materials,
X-ray, Dialysis, chemotherapy, Radio therapy, cost of
pacemaker, Artificial limbs, cost or organs and similar
expenses.

4. HEALTH INSURANCE IN INDIA
 In the year 2016, the NSSO released the report “Key Indicators of
Social Consumption in India: Health” based on its 71st round of
surveys. The survey carried out in the year 2014 found out that, more
than 80% of Indians are not covered under any health insurance plan,
and only 18% (government funded 12%) of the urban population and
14% (government funded 13%) of the rural population was covered
under any form of health insurance.
 There are standalone health insurers along with government
sponsored health insurance providers. Until recently, to improve the
awareness and reduce the procrastination for buying health
insurance, the General Insurance Corporation of India and
the Insurance Regulatory and Development Authority (IRDA) had
launched an awareness campaign for all segments of the population.
 Tax benefits :Under Section 80D of the Income tax act the insured
person who takes out the policy can claim for tax deductions
• ₹25,000 for self, spouse and dependent children.
• ₹50,000/- for parents.

5. TYPES OF POLICIES
 Hospitalization
 Hospitalization plans are indemnity plans that pay cost of hospitalization
and medical costs of the insured subject to the sum insured. The sum
insured can be applied on a per member basis in case of individual
health policies or on a floater basis in case of family floater policies. In
case of floater policies the sum insured can be utilized by any of the
members insured under the plan. These policies do not normally pay any
cash benefit. In addition to hospitalization benefits, specific policies may
offer a number of additional benefits like maternity and newborn
coverage, day care procedures for specific procedures, pre- and post-
hospitalization care, domiciliary benefits where patients cannot be
moved to a hospital, daily cash, and convalescence.
 There is another type of hospitalization policy called a top-up policy. Top
up policies have a high deductible typically set a level of existing cover.
This policy is targeted at people who have some amount of insurance
from their employer. If the employer provided cover is not enough
people can supplement their cover with the top-up policy. However, this
is subject to deduction on every claim reported for every member on
the final amount payable.

6.  Pre-Existing Disease Cover Plans:It offers covers against disease
that policyholder had before buying health policy. Pre-Existing
Disease Cover Plans offers cover against pre-existing disease e.g
diabetes, kidney failure and many more. After Waiting period of
2 to 4 years it gives all covers to insurer..
 Senior Citizen Health Insurance: As name suggest These kind of
health insurance plans are for older people in the family. It
provide covers and protection from health issues during old age.
According to IRDA guidelines, each insurer should provide cover
up to the age of 65 years.
 Maternity Health Insurance: Maternity health insurance ensures
coverage for maternity and other additional expenses. It takes
care of both pre and post natal care, baby delivery (either
normal or caesarean). Like Other Insurance, The maternity
insurance provider have wide range of network hospitals and
takes care of ambulance expense.
 Hospital daily cash benefit plans: Daily cash benefits is a defined
benefit policy that pays a defined sum of money for every day
of hospitalization. The payments for a defined number of days in
the policy year and may be subject to a deductible of few days.

7.  Critical illness plans: These are benefit based policies which pay a
lumpsum (fixed) benefit amount on diagnosis of covered critical illness
and medical procedures. These illness are generally specific and high
severity and low frequency in nature that cost high when compared to
day to day medical / treatment need. e.g. heart attack, cancer, stroke
etc. Now some insurers have come up with option of staggered
payment of claims in combination to upfront lumpsum payment.
 Pro active plans: Some companies like Cigna TTK offer Pro active living
programs. These are designed keeping in mind the Indian market and
provide assistance based on medical, behavioral and lifestyle factors
associated with chronic conditions. These services aim to help
customers understand and manage their health better.
 Disease specific special plans: Some companies offer specially designed
disease specific plans like Dengue Care. These are designed keeping in
mind the growing occurrence of viral diseases like Dengue in India
which has become a cause of concern and thus provide assistance
based on medical needs, behavioral and lifestyle factors associated with
such conditions. These plans aim to help customers manage their
unexpected health expenses better and at a very minimal cost.

8. EMPLOYEES STATE INSURANCE SCHEME
 The ESI scheme, introduced by an Act of Parliament in 1948 , It
has introduced for the first time in India the principle of
contribution by the employer and employee. The Act besides full
medical care for self and dependants, that is admissible from day
one of insurable employment, the insured persons are also
entitled to a variety of cash benefits in times of physical distress
due to sickness, temporary or permanent disablement etc.
resulting in loss of earning capacity, the confinement in respect of
insured women, dependants of insured persons who die in
industrial accidents or because of employment injury or
occupational hazard are entitled to a monthly pension called the
dependants benefit. drawing wages not exceeding ₹15,000 per
month

9. CENTRAL GOVERNMENT HEATH SCHEME
 It was first introduced in New Delhi in 1954 to provide comprehensive medical care
to Central Government employees. The scheme is based on the principle of
cooperative effort by the employee and the employer, to the mutual advantage of
both. The medical facilities are provided through Wellness Centres (CGHS
Dispensaries) Allopathic, Ayurveda, Yoga,Unani, Sidha and Homeopathic systems of
medicines.
 The main components of the Scheme are:
• The dispensary services including domiciliary care
• F. W. & M.C.H. Services
• Specialists consultation facilities both at dispensary, polyclinic and
hospital
• level including X-Ray, ECG and Laboratory Examinations.
• Hospitalization
• Organization for the purchase, storage, distribution and supply of medicines and
other requirements
• Health Education to beneficiaries

10. RASHTIYA SWASTHIYA BIMA YOJANA (RSBY)
 RSBY ( Rashtriya Swasthiya Bima Yojana) has been
launched by Ministry of Labour and Employment, Government of
India to provide health insurance coverage for Below Poverty Line
(BPL) families. Beneficiaries under RSBY are entitled to
hospitalization coverage up to ₹30,000/- for most of the diseases
that require hospitalization. Government has even fixed the
package rates for the hospitals for a large number of
interventions. Pre-existing conditions are covered from day one
and there is no age limit. Coverage extends to five members of
the family which includes the head of household, spouse and up
to three dependents. Beneficiaries need to pay only ₹30/- as
registration fee while Central and State Government pays the
premium to the insurer selected by the State Government on the
basis of a competitive bidding.

11. UNIQUE FEATURES OF RSBY
 Empowering the beneficiary– RSBY provides the participating BPL household with
freedom of choice between public and private hospitals and makes him a potential
client worth attracting on account of the significant revenues that hospitals stand to
earn through the scheme.
 Business Model for all Stakeholders– The scheme has been designed as a business
model for a social sector scheme with incentives built for each stakeholder. This
business model design is conducive both in terms of expansion of the scheme as
well as for its long run sustainability
 Intermediaries– The inclusion of intermediaries such as NGOs and MFIs which have
a greater stake in assisting BPL households. The intermediaries will be paid for the
services they render in reaching out to the beneficiaries.
 Government– By paying only a maximum sum up to ₹750/- per family per year, the
Government is able to provide access to quality health care to the below poverty
line population
 Information Technology (IT)
 Safe and foolproof
 Portability– The key feature of RSBY is that a beneficiary who has been enrolled in a
particular district will be able to use his/ her smart card in any RSBY empanelled
hospital across India.
 Cash less and Paperless transactions

12. AYUSHMAN BHARAT YOJANA
 Ayushman Bharat Yojana or Pradhan Mantri Jan Arogya
Yojana (PMJAY) or National Health Protection Scheme or ModiCare is
a centrally sponsored scheme launched in 2018, under the Ayushman
Bharat Mission of MoHFW in India. The scheme aims at making
interventions in primary, secondary and tertiary care systems,
covering both preventive and promotive health, to address
healthcare holistically.
 It is an umbrella of two major health initiatives namely, Health and
Wellness centres and National Health Protection Scheme (NHPS).
The National Health Protection Scheme (NHPS) scheme is formed by
subsuming multiple schemes including Rashtriya Swasthya Bima
Yojana, Senior citizen health Insurance Scheme (SCHIS), Central
Government Health Scheme (CGHS), Employees' State Insurance
Scheme (ESIS) etc. Further, the National Health Policy, 2017 has
envisioned Health and Wellness Centres as the foundation of India’s
health system which the scheme aims to establish.

13. KEY FEATURES OF PM-JAY
 Provides hospitalisation cover of up to ₹5,00,000 per entitled family per year.
 More than 10.74 crore poor and vulnerable families (approximately 50 crore
beneficiaries) covered across the country.
 Entitlement based scheme. No formal enrolment process is required.
 Poor, deprived rural families and identified occupational category of urban
workers’ families as per the latest Socio-Economic Caste Census (SECC) 2011 data,
both rural and urban will be covered. In addition, all enrolled families under
Rashtriya Swasthaya Bima Yojana (RSBY) that do not feature in the targeted groups
as per SECC data will be included as well. Details of the beneficiary categories is
given in Annexure 1.
 No cap on family size and age of members. All members of designated families
get coverage; specifically, girl child and senior citizens.
 Covers secondary and tertiary care hospitalization.
 Free treatment available at all public and empanelled private hospitals.
 Cashless and paperless access to quality health care services.
 Benefits of national portability. Eligible beneficiaries can avail services across India.
 1,350 medical packages covering surgery, medical and day care treatments, cost of
medicines and diagnostics.
 All pre-existing diseases covered.

14. HIMACHAL PRADESH UNIVERSAL HEALTH
PROTECTION SCHEME
 Launched 2nd August, 2017 To improve access, of enrolled beneficiaries and their families to
quality healthcare for cashless treatment of diseases involving hospitalization through
empanelled healthcare providers. There will be no family cap. Maximum five members can be
enrolled in a smart card so if the family size will be more than five, one additional card will be
given to the family.
 Pre-existing conditions/diseases are covered from the first day of the start of Policy. Coverage
of health services related to surgical nature for defined procedures shall also be provided on a
day care basis.
 Pre and post hospitalization costs up to 1 day prior to hospitalization and up to 5 days from
the date of discharge from the hospital shall be part of the package rates under basic Package.
And up to 15 day prior to hospitalization and up to 60 days from the date of discharge from
the hospital shall be part of the package rates under critical care Package. The benefit will be
provided through only smart card.
 Inpatient Cover of Rs. 30,000/- per family (5 members) per annum, Critical Diseases Rs.
1,75,000/-, For Cancer Patients Rs. 2,25,000/-. Beneficiary family will pay Rs. 1 per day /Rs. 365
per year. Additional card will be issued for family having more than five members Rs. 1/- per
day.
 The beneficiaries of this scheme are all APL/BPL card holders issued by Dept. of Food and Civil
Supplies, Govt. of Himachal, Who are registered on HPUHPS Portal for smart card under the
scheme.(Except covered under any other Govern ment Scheme). The eligible family needs to
come to the enrollment station, and the identity of the household head needs to be confirmed
by the authorized official.

16. HIMCARE
 Announced on Jan 3 , 2019 this policy shall be called ‘The
Himachal Health Care Scheme’ in short HIMCARE.
 Cashless treatment coverage of Rs. 5.00 lakh per year per family
will be provided under the scheme on family floater basis subject
to maximum of five members per family unit. In case family size
exceeds five members, the remaining members can be enrolled
as a separate unit subject to the capping of five members for
each such addition unit. The treatment will be provided on the
basis of pre-defined package rates in the empanelled hospitals.
 The premium will be collected from beneficiaries at the time of
enrollment under the Himachal Healthcare Scheme based on
various categories, including BPL, Asha workers, Ekal Nari, mid-
day meal workers and disabled persons
 The premium amount is ₹365 per year excluding all beneficiers
under HPUHPS or who are not govt. servants or their dependent
family members.

17. OTHER AGENCIES
 Defence Medical Services Defence services have their own
organization for medical care to defence personnel under the
banner "Armed Forces Medical Services". The services
provided are integrated and comprehensive embracing
preventive, promotive and curative services.
 Health Care of Railway Employees The Railways provide
comprehensive health care services through the agency of
Railway Hospitals, Health Units and clinics. Environmental
sanitation is taken care of by Health Inspectors in big stations.
A chief Health Inspector supervises the division's work. Heath
check-up of employees is provided at the time of entry into
service, and thereafter at yearly intervals. There are lady
medical officers, health visitors and midwives who look after
the MCH and School Health Services. Specialists services are
also available at the Divisional Hospitals.

18. PUBLIC AND PRIVATE AGENCIES
 In a mixed economy such as India's, private companies
provide a lot of different varieties of health insurances
and health covers . The higher costs of the private
sector, however, are out of reach of many Indians,
generating demand for public health insurance in
India.
 Government Health Insurance Companies
• The New India Assurance Co . ltd
• United India Insurance Company
• National Insurance Co.ltd
• Oriental Insurance

19.  Private Health Insurances
 Apollo Munich Health Insurance Company Limited
 Star Health and Allied insurance Co Ltd
 Future Generali India Insurance Company Ltd
 Bajaj Allianz General Insurance Co Ltd
 Cigna TTK
 Iffco Tokio General Insurance Co Ltd
 Bajaj Allianz Health Insurance

20. THANKS