Irda Vol 6 Iss 2 (Jan 08) Final

Volume VI, No.
January 2008
Getting
BETTER and BETTER...
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IRDA Vol 6 Iss 2 (Jan 08) FINAL.pmd 1 1/7/2008, 4:54 PM
Editorial Board
C.S. Rao
C.R. Muralidharan
S.V. Mony
K.N. Bhandari
Vepa Kamesam
Ashvin Parekh
Editor
U. Jawaharlal
Hindi Correspondent
Sanjeev Kumar Jain
Printed by Alapati Bapanna and
published by C.S.Rao on behalf of
Insurance Regulatory and Development Authority.
Editor: U. Jawaharlal
Printed at Kalajyothi Process Ltd.
(with design inputs from Wide Reach)
1-1-60/5, RTC Cross Roads
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Phone: +91-40-66820964, 66789768
Fax: +91-40-66823334
e-mail: irdajournal@irda.gov.in
© 2007 Insurance Regulatory and Development Authority.

Please reproduce with due permission.
Unless explicitly stated, the information and views published in this
Journal may not be construed as those of the Insurance Regulatory
and Development Authority.

From the Publisher
H
ealth insurance is the emerging segment any cross-subsidization from other classes. The
in both life and general insurance. As a process of detariffing has taken care of this aspect
class, it has surpassed several others to a great extent. An efficient upfront
although it is of a more recent origin. The rapid underwriting would go a long way in addressing
growth that it has been recording in recent times several problems associated with health insurance.
also speaks volumes of its importance. In a country This would minimize, if not avoid the large scale
where the total coverage of the population under dissatisfaction about the management of the
any form of healthcare protection, including state- portfolio by the insurers. The service providers,
provided and employer-provided schemes, does on their part, should make efforts to erase the
not go into double digit figures; a sustained commonly held belief that they fleece the
growth is welcome. customers if they have insurance cover. The
system can be improved; provided, the insurers,
Considering the huge potential in the country as the insured and the service providers jointly put
also the growing income levels and other visible in efforts to remove some of the weaknesses in
growth, insurers should ensure that health the existing system.
insurance continues to register a steady rise in
The focus of this issue of the Journal is on ‘Health
the near future. In order to achieve this, there is
Insurance’. In order that wealth creation and
need for widening the client base – not merely
wealth management processes are wholesome,
by marketing strategies but by ensuring that more
it is very essential to have in place suitable and
and more people understand the importance of
sufficient insurance coverage; whether it is for
having in place proper health insurance coverage.
an individual or for a corporate entity. ‘The role
This would be possible by enhancing the
of insurance in Personal Financial Planning’ will
distributors’ skills and also ensuring that all the
be the focus for the next issue of the Journal.
other parties involved viz. the third party
administrators, the service providers etc. are
geared up to meeting the challenges of this
sensitive area of operation.
The real test of success for any class of insurance

C.S. Rao
lies in its ability to sustain individually, without

Statistics - Life Insurance 4
Vantage Point
U. Jawaharlal 6
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Statistics - Non-Life Insurance 46

D
Round-up 47
ISSUE FOCUS
I
Health Insurance in India

- K. Sujatha Rao 10
Sustainable Private Health Insurance

- Dr. Tilman Ehrbeck 12
S
Designing New Health Insurance Products

- Richard Kipp and Thomas Snook 17
Health Security for All

- Dr. Somil Nagpal, Dr. N Devadasan and Nehal Jain 25
A Case Study for Micro Health Insurance

N
- Rameshwari Kharva 31
I
FOLLOW THROUGH
Agriculture Insurance in India
- S.S. Kukreja and Gaurav Nagar 35

from the editor
Health Insurance
- Key for Betterment of Society
I
ndia has made tremendous progress in the field of healthcare over the last few decades. Several nagging
problems have been put to rest and we have eradicated some of the killer epidemics (Smallpox, for example).
Research in the field of medicine has also been improving, to be in tandem with the developments taking
place elsewhere in the globe. Healthcare delivery to the common man, however, has remained a highly debated
issue; and there are several millions of people who remain out of access to even the basic amenities as regards
personal care and hygiene. One of the reasons assigned for such an unfortunate situation is the vast geographical
spread of the population that remains out of reach for regular medical facilities. For an economy that is
growing at a faster rate than most developed nations, there is an urgent need for overcoming such irritants.
Another oft-quoted reason for such a situation is the poverty that is the bane of several of these masses. The
total percentage of the Indian population that is covered under the umbrella of any form of healthcare protection
is pathetically low. While the intention is not to parade insurance as a panacea for all the ills of the society, by
improving the numbers of health insurance penetration among a larger section of people who can afford it; we
will be creating a platform for the state to concentrate on the less-privileged sections. Unfortunately, health
insurance as a viable alternative has not been able to make giant strides of progress, although it has been
growing, of late.
A strong factor for the poor performance of health insurance historically has been the moral hazard associated
with it. Because of the poor awareness levels about insurance even among the educated elite, exclusive risk
coverage schemes have not gained popularity in the Indian domain. Having paid the premium for a certain
period, the policyholder imagines an inherent right in the enforcement of a claim. In several instances, he is
aided in the process by service providers reportedly; and the entire episode results in a huge claims ratio for the
insurers that puts them on the back foot. There is need for all the stakeholders to make the insured understand
the basic elements of the insurance coverage. Some areas that insurers on their part may work on are widening
the coverage of the policies – perhaps encouraging preventive care among the insured, for one. It is also
essential that all the stakeholders join shoulders to take the cause further and ensure that health insurance in
India reaches world-class standards.
The focus of this issue of the Journal is ‘Health Insurance’. The first article of this highly topical issue is by Ms.
K. Sujatha Rao, in which she brings in her experiences as a civil servant; and mentions that for the health
insurance system to be successful in India, competition in healthcare supply plays a key role. In the next article
by Dr. Tilman Ehrbeck, you get to see some global experiences in the area of health insurance; and lessons for
the Indian market. The next article is by Mr. Richard Kipp and Mr. Thomas Snook, who emphasize on the
importance of data collection and analysis which are so vital for product designing and pricing. There have been
quite a few schemes promoted by the government – both at the national and state levels; and they have
enjoyed mixed success. The details of many of such schemes with threadbare analysis are brought home succinctly
in the next article by Dr. Somil Nagpal, Dr. N. Devadasan and Ms. Nehal Jain. Several NGOs have been very
actively working in different parts of the country, promoting the cause of health insurance at the grass-root
level. We have a case study of one such NGO working in Gujarat, by Ms. Rameshwari Kharva. In the end, there
is an article under the ‘follow-through’ section by Mr. S.S. Kukreja and Mr. Gaurav Nagar that talks about the
role for both the public and private sector insurers in the promotion of agriculture insurance in the country.
To have in place proper insurance covers for various assets is as important for an individual as it is for a corporate
entity. The role of insurance in Personal Financial Planning will be the focus of the next issue of the Journal.
We wish all our readers a happy and prosperous NEW YEAR 2008.
U. Jawaharlal

IRDA Vol 6 Iss 2 (Jan 08) FINAL.pmd
Report Card:LIFE
statistics - life insurance

First Year Premium of Life Insurers for the Period Ended November, 2007
Sl
Premium u/w (Rs. in Crores) No. of Policies / Schemes No. of lives covered under Group Schemes
No. Insurer
6
Nov, 07 Up to Nov, 07 Up to Nov, 06 Nov, 07 Up to Nov, 07 Up to Nov, 06 Nov, 07 Up to Nov, 07 Up to Nov, 06
1 Bajaj Allianz
Individual Single Premium 69.97 366.77 699.79 8217 55272 56079
Individual Non-Single Premium 379.16 2712.00 1109.74 255620 1978028 689916
Group Single Premium 1.15 8.13 3.54 0 0 1 763 5720 1367
Group Non-Single Premium 1.06 14.25 14.36 14 172 146 50997 508673 521549
2 ING Vysya
irda journal

3 Reliance Life
4
4 SBI Life
Jan 2008

5 Tata AIG
1/7/2008, 4:54 PM

6 HDFC Standard
7 ICICI Prudential
8 Birla Sunlife
9 Aviva
IRDA Vol 6 Iss 2 (Jan 08) FINAL.pmd
statistics - life insurance

10 Kotak Mahindra Old Mutual
11 Max New York
12 Met Life
7

13 Sahara Life
14 Shriram Life
irda journal

15 Bharti Axa Life
5

Jan 2008
16 Future Generali *
1/7/2008, 4:54 PM
Private Total
17 LIC
Grand Total
Note: 1.Cumulative premium upto the month is net of cancellations which may occur during the free look period.
2. Compiled on the basis of data submitted by the Insurance companies.
3. * Commenced operations in November, 2007.
vantage point
Insurance – Essential Part of One’s Portfolio

U. JAWAHARLAL MENTIONS THAT IN ORDER TO ENJOY THE COMFORT OF NOT BEING DEVASTATED BY LOSS OF PERSONAL
ASSETS, IT IS VERY IMPORTANT TO KEEP IN PLACE PROPER INSURANCE COVERS. HE FURTHER ADDS THAT WEALTH
MANAGEMENT IS AS IMPORTANT AS WEALTH CREATION.
A
proper planning and budgeting for rates and inflation, personal financial insurance, it is vital for individuals to have
a corporate body are of vital planning has assumed a more complex in place sufficient coverage against the
importance. The risks that are character. Further, the onset of various possibility of falling sick. Though for
inherent in running a business necessitate financial instruments in the market has different reasons, health insurance is also
that unless there is a planned approach added to the complexity of the matter and a complicated issue when it comes to
that takes care of both the strategic and one has to be an expert in several areas to convincing the masses about its
tactical needs, it is sure to run into rough ensure a balanced personal financial importance.
weather, sooner or later. Management planning for oneself. This is easier said than
Similarly, there are several other personal
experts very often compare an entity done.
assets that need to be sufficiently and
without sufficient planning to an ocean
The role of insurance in wealth properly covered under suitable insurance
liner that is merrily cruising along,
management is a monumental one. It is policies. In the Indian context, it is
blissfully unaware of the rocks that it might
very essential that all the assets created mandatory requirement that is a stronger
hit along its path. However, it is not that
over a period of time with all the hard work driving force rather than a voluntary
such a planning is required only for business
are properly protected against the risks participation that makes people resort to
houses – it is equally important for
associated with their existence. Above all, insuring their assets. A sense of
individuals. Personal financial planning can
for individuals it is very important to be complacency that nothing happened
be considered as the process by which an
insured sufficiently against the unfortunate earlier compels people to believe that no
individual or a family can develop and
event of untimely death. There has to be insurance is required. They should learn
implement an integrated plan to
a proper planning that in the event of such from the experiences of others and ensure
accomplish objectives. Hence, personal
a scenario, the dependents continue to that they continue to enjoy such a comfort.
financial planning can be said to be a two-
maintain the same standard of living. In As against only a few coverages earlier,
stage process – to identify the overall goals
the case of life insurance, historically the today there are insurance covers for almost
and objectives; and then to develop and
Indian society has suffered from fatalistic all conceivable risks for various assets.
implement an integrated plan to achieve
overtones; and it used to be very tough Individuals should get to learn about the
them.
convincing individuals about the various packages that insurers offer and
In the earlier times, the process of personal importance of being insured sufficiently for protect themselves against the increasingly
financial planning used to be a much life. Although there has been a great deal risky environment that they are living in.
simpler task. However, in light of the of improvement in this regard, insurance
‘The Role of Insurance in Personal Financial
greater economic uncertainty dealing with is still not treated as a priority for various
Planning’ will be the focus of the next issue
such variables as ever-changing interest reasons. Close on the heels of life
of the Journal.
Securing Personal Assets
in the next issue...
irda journal 6 Jan 2008

in the air
CIRCULAR
December 18, 2007 Ref: 048/IRDA/De-tariff/Dec-07
To Insurers may file a fresh schedule of rates and rating guidelines

The CEOs of All General Insurance Companies, with the Authority or may maintain the schedules and rating
guidelines that have already been filed.
Sub: Removal of controls on pricing of risks in general insurance
business with effect from 1st January, 2008 The requirements of the circular no. 021/IRDA/F&U/Sep-06 dated
28th September 2006 with regard to the filing of products and
The issues relating to the removal of controls on pricing of risks in rates schedules and rating guides and manuals shall continue to
the general insurance business was discussed at a meeting with apply as amended from time to time.
the CEOs of general insurers at Hyderabad on 14 December 2007.
The Authority will accept the rate schedules and rating guides as
It was clarified by the Authority at the meeting that the Guidelines filed by the insurer on the stipulation that these are in compliance
on File and Use procedures in respect of general insurance products with the underwriting policy as approved by the respective Boards
as detailed in the Authority’s circular no. 021/IRDA/F&U/Sep-06 of Directors and on the condition that they are designed so as to
dated 28th September 2006 will continue to apply and insurers produce an operating ratio [incurred claims plus commission and
shall continue to file the rates and terms that they wish to offer expenses of management] not exceeding 100% on a gross
for various products including the products covered by the erstwhile underwriting basis. However, the Authority retains the right to
tariffs. The CEOs assured the Authority that the high standards of query or require changes to any such rates schedules and rating
underwriting and market conduct will be maintained by all insurers guides, at its sole discretion.
even after the price controls are removed.
Any revision in rates shall only be given effect to on renewal
On the basis of these assurances, the Authority has decided as date of the insurance and insurers shall not be permitted to cancel
follows: existing insurances and replace them by new insurances at revised
Except for Motor Third Party risks, for all other new insurances rates. The insured has, however, the right to require cancellation
and renewals effective on or after 1 January 2008, insurers shall of his insurance in which case, premium at short period scale as
be free to quote rates of premium in accordance with the rate applicable shall be chargeable.
schedules and rating guidelines that have been filed with the The terms & conditions of cover and the wordings of policies,
Authority. endorsements, warranties and clauses set out in the erstwhile
The premium rates for Motor Third Party risks will continue to tariffs shall continue to apply until fresh market wordings are
be regulated by the Authority. examined and accepted by the Authority after considering the
views of various stakeholders.
Risks qualifying as large risks under paragraph 19(v) of the circular
no. 021/IRDA/F&U/Sep-06 dated 28th September 2006 shall be
(C.S. Rao)
insured at the rates, terms and conditions and basis of insurance
Chairman
exactly as the rates, terms etc. as developed from the reinsurers
with no variation.
PRESS RELEASE
December 19, 2007
Insurance Regulatory and Development Authority
IDBI Fortis Life Insurance Co. Ltd, a joint venture life insurance total number of life insurers registered with the Authority has
company promoted by IDBI, Federal Bank, India and Fortis gone up to 18.
Insurance International, Netherlands has been registered as a
Life Insurer under Section 3 of the Insurance Act, 1938 with the (C R Muralidharan)
Authority. The Certificate of Registration (Forms IRDA/R3) has Member
been issued by the Authority today. With this registration, the

in the air
NOTICE
20th December, 2007
Re: Elected Council of the Indian Institute of Insurance Surveyors and Loss Assessors
As envisaged in Article 15(6) of the Articles of Association of the 15.12.2007. The following were elected as the office-bearers
Indian Institute of Insurance Surveyors and Loss Assessors, with from amongst the elected members:
the completion of the initial membership processing and the 1. Shri M J Dhruva - President
successful conduct of the first elections to the Council, the 2. Dr. R A Srinivas - Vice-President
management of the Institute, promoted by IRDA, was formally 3. Shri Arun Kumar - Secretary
transferred to the office bearers of the newly elected council at 4. Shri Jawahar Lal Tiku - Treasurer
its meeting held at the registered office at Hyderabad on
(Suresh Mathur)
Nominee Council Member
CIRCULAR
1st January, 2008
To b) Information specific to the particular policy holder only

All Life Insurers shall have to be used.
Sub: Benefit illustrations for Unit Linked Products c) Insurers must also give figures separately in a table about
Please refer to our earlier letter dated No.2/IRDA/ACTL/DC/ guaranteed benefits and non-guaranteed benefits for
2007-08 dated 17th December, 2007, requesting comments on the each policy year (Table-B) keeping in view the interest
captioned draft circular. We are thankful to those who were kind rates as specified by the Life Insurance Council’s circular.
enough in sending their responses. At present the interest rates used for benefits illustration
The purpose of this circular is to provide the prospect / are 6% p.a. and 10% p.a. respectively. This table (Table-
policyholder all relevant information regarding amounts deducted B) is already in practice.
towards various charges for each policy year so that the prospect d) The policy holder must sign both Table-A and Table-B
/ policyholder can take an informed decision. The present step along with the sales person on the day when he she
will no doubt pave the way towards standardizing the disclosures signs the proposal form. These tables shall become part
which would result in greater transparency and enhanced of policy document and a copy must be sent to the policy
policyholders’ confidence. You all will agree that this is crucial holder along with the policy document.
at this hour as unit linked products are assuming significant share e) The circular is applicable to all unit linked products (both
in the total portfolio. In this context, the following are to be new and existing) and shall come into force with effect
ensured: from February 1, 2008.
a) Life insurance companies are required to confirm to the
format (Table-A) enclosed which lists out all charges to Please acknowledge the receipt of the circular.
be paid and also the amount available for investment in
each policy year. (R. Kannan)
Member (Actuary)

in the air
TABLE-A
(Applicable to Linked Products)
(This shall form a part of the policy document)
Proposal No:
Policy No:
PRODUCT FEATURES
1. Name of the Product: 2. Unique Identification Number:
3. Sum Assured: 4. Policy Term:
5. Premium Payment Term:
6. Mode of Premium: SP/Non SP (If non SP, indicate the mode)
7. Amount of Installment Premium:
8. Statement of Charges and Amount for Investment
(In Rupees)
At the start of 1 2 3 4 5 6 7 8 9 10 and

the Policy Year so on
Amount of
installment Premium
Amount of Premium
Allocation Charge
Amount of
any other charge
(Please specify clearly)
a)
b)
c)
d)
Sub Total
Total Charges
Amount allotted for investment
IN THIS POLICY, THE INVESTMENT RISK IS BORNE BY THE POLICY HOLDER

Note:
1. Some charges are collected immediately after the allocation is made, through cancellation of units. Please specify these
charges with rates.
2. Some charges are collected at the end of the year, through cancellation of units. Please specify these charges with rates.
3. Policyholder should receive a document (the glossary for various terms of charges used) from the insurer.
I………………………….. (Name), having received the information with respect to the above, have understood the above statement
before entering in the contract.
Marketing officials’ Policyholders’ Signature

Signature:
Company Seal:
Place:
Date:

issue focus
Health Insurance in India

A COMMENT
K. SUJATHA RAO AVERS THAT UNIVERSAL SOCIAL HEALTH INSURANCE SYSTEM HAS REMAINED A DISTANT DREAM; AND IN
ORDER TO ACHIEVE THAT, IT IS ESSENTIAL THAT THERE IS AN ATTEMPT TO CREATE A STRONG COMPETITIVE ENVIRONMENT,
WHICH CAN ONLY BE POSSIBLE WHEN THE PUBLIC SECTOR HOSPITALS PROVIDE EVEN BETTER STANDARDS OF CARE
THAN THAT PROVIDED BY THE PRIVATE SECTOR.
I
t was over a decade ago that the reducing the payouts against the sums The implications of achieving the above
Ministry of Health started to discuss the collected, high premia can be a barrier to mentioned conditions require the
relevance of health insurance in India. get the desired size and composition of the redefinition of the role of the state from
Two workshops were held with lead experts pool. If India continues to struggle in search being a provider of care to a regulator and
in the field. It was clear then that there of a viable health insurance model, despite standard setter. In the absence of the state
were four important issues that required engaging with this idea for over a decade, playing such a role, the patients are getting
immediate policy attention if universal it is because of our inadequate shortchanged. Today’s health insurance
health insurance were to be an option to understanding of the fundamental drivers system in India is weighted in favour of
public health financing: legal frameworks of the model. the providers and the insurance
to regulate the providers in general and
For ensuring low premia and financial
the private sector in particular; systems
viability, there are four important
of accreditation to promote quality of care
conditions the health system must fulfill:
and value for money; organizing
• Have the insured stay healthy and avoid
information systems to obtain more
illness or risk factors such as by
rigorous estimates of disease incidence;
promoting exercise, tobacco control,
and focusing on prevention of disease.
nutrition, sanitation, access to safe
The above mentioned policy interventions drinking water etc; While viability can be
are critical to the feasibility of health
• Ensuring providers do not over- or under- assured with
insurance in India. Regulation enables
treat; and implement safety standards reducing the payouts
provider control, while accreditation
assures standardization of service delivery,
to ensure the hospitalized patients do against the sums
not acquire new infections which are
so necessary for patient satisfaction.
often harder to treat;
collected, high
Information gives insights on where to
• Have treatment protocols defined and
premia can be a
focus resources to prevent disease and
costed to keep control on the costs of barrier to get the
frequency in occurrence of illness
episodes. All these are critical
care; and desired size and
requirements for viability of insurance • In a mixed model of care as in India, a composition of the
since it is based on the principle of subsidy strong public sector delivery system pool.
between the healthy, the rich and the which alone can force the private sector
young; against the ill, the poor and the to provide standard quality of care at
old. While viability can be assured with low prices.

issue focus
companies, and not the patient; and hence substantive budgetary outlays which
does not help achieve the objective of governments cannot afford. The second
alleviating the overall public health option is to work within the mixed provider
standards and well being in the country. The current system of system by creating a strong competitive
The current system of insurance for an environment, which can only be possible
insurance for an
assured sum puts no pressure on the when the public sector hospitals provide
provider to contain costs or on the insurer assured sum puts no even better standards of care than that
to ensure containing costs. This pressure on the provided by the private sector. By
combination is the main reason for the provider to contain mandating health insurance among
wide prevalence of unethical care where government employees and the private
costs or on the
procedures and tests are performed even organized sector, adequate stimulation can
when the patient does not need or claiming
insurer to ensure be engineered to enable a viable social
reimbursements from insurance companies containing costs. health insurance. The sooner work is
for services not performed. Government’s started along these lines and a standalone
inability to creating a viable risk pool, by health sector regulator instituted, the
merging the CGHS and ESIS to create a better for achieving our dream of having a
viable structure for social health insurance universal social health insurance system in
and following instead a hundred flowers the country.
bloom policy is flawed. Small insurance
cost controls - every limit only enhancing
pools with members from the poor quintiles
the cost.
cannot in any substantive manner address
the major cause of impoverishment, India has only two options to provide real
namely hospitalization. For example, one financial risk protection to its people: The author is an IAS Officer of the AP cadre
and is presently the Director General of the
case of appendectomy can be enough to having social health insurance by National AIDS Control Organization (NACO).
wipe out the reserve of the family and the enhancing public investment in health like She was earlier the Secretary of the National
Commission on Macroeconomics and Health
risk pool. In such a case limits are placed Canada, Australia or UK. This, though ideal, prior to her current assignment. Views
but are of little value in the absence of is not possible as it requires very expressed are in her personal capacity.

issue focus
Sustainable
Private Health Insurance
GLOBAL PERSPECTIVES FOR INDIA
DR. TILMAN EHRBECK WRITES THAT RISING INCOME LEVELS COMPLEMENTED BY HEALTHCARE AWARENESS ARE BOUND
TO GROW OVERALL HEALTHCARE COSTS AS HAS BEEN THE EXPERIENCE IN NEARLY EVERY DEVELOPED COUNTRY,
WHERE HEALTHCARE COSTS HAVE BEEN GROWING AT A RAPID RATE FOR DECADES.
A s income levels and health awareness

rise, the emerging Indian middle class
will seek better underlying medical
specific recommendations but focuses on
perspectives and facts on some of the key
issues the country’s health insurance sector
services and cover for the financial risks faces to provide context for the discussion Given its
that come with the more sophisticated and in the country.1
demographics and
expensive medical care nowadays
available. To provide the desired broader
Against the backdrop of the current stage of
industry structure and predominant
coverage in a financially sustainable product offering, three sets of lessons
development, India
fashion is both an opportunity and a learned from international experiences will need a tailored
challenge for India’s nascent health seem relevant: approach to meet
insurance industry.
• Capabilities required for a retail health this challenge, and it
Given its demographics and stage of insurance market. While relatively well has the opportunity
development, India will need a tailored penetrated, the employer-based group
approach to meet this challenge, and it health insurance market in India is small
to learn from
has the opportunity to learn from relevant – it includes less than 10 per cent of the relevant international
international experiences and avoid some workforce. At the same time, experiences and
of the mistakes made by other countries. government insurance coverage is avoid some of the
This paper discusses the contributions limited, and the planned expansion
focuses on the poor at the base of the
mistakes made by
India’s private health insurance sector
could make. It does not provide a series of economic pyramid.2 As a result, the other countries.
1 This paper draws on materials the author and his colleagues Dr. Vishal Agrawal, Dr. Viktor Hediger, and Shubham Singhal prepared for the November 2007 FICCI
conference on Sustainable Health Insurance.
2 The Government of India has announced plans for subsidised health insurance for the country’s poorest citizens in the unorganised sector. If successfully
implemented, such a scheme would provide better access and a higher standard of healthcare to a significant portion of the Indian population. A successful
national health insurance model for the poor should build on India’s successful experiments with micro health insurance covered in the November 2007 edition
of the IRDA Journal and leverage three unique strengths of the country: its strong civic institutions, its active and entrepreneurial healthcare markets, and its
tradition of decentralisation. In such a model, the government would act as a market maker and regulator. A more comprehensive discussion of this topic is
beyond the scope of this paper.

issue focus
majority of the opportunity lies in Product innovation

privately provided and individually Individuals face a number of exposures
purchased health insurance products for driven by health and health-related events
the emerging middle class. To meet its and costs, the risks of which they can bear
needs requires product and channel to differing degrees. These risks range
innovations and the ability to price risk from low ticket-size expenses (e.g., for Health insurance
appropriately. routine care) to higher ticket-size products are likely to
• Health insurance coverage beyond discretionary expenses (e.g., for elective require additional
surgery), catastrophic expenses (e.g., due
hospitalization benefits. Currently, distribution channels
health insurance products in India to major illness, accident), end-of-life care
expenses (e.g., due to life-threatening beyond the dominant
narrowly cover hospitalization benefits
with a sum-assured limit. India’s private illness), expenses related to chronic agency force.
health insurance sector could cover a diseases and income risk (e.g., disability).
number of secondary and tertiary Successful innovation combines the
preventive measures such as screening elements of an appropriate financing
for cancer or diabetes, and preventive mechanism, managed care, and advice to
health check ups as well as disease help consumers deal with these different
management programs for specific types of health-related risks. In the U.S.,
conditions, which would be beneficial for traditional products have focused on an older age would serve the needs of such
insured and insurers alike. mainly providing insurance as the financial consumers.
• Techniques to manage medical value. vehicle with select managed care
The combination of rising income levels elements. Recently introduced consumer- Channel innovation
and awareness as well as broader directed health plans combine savings and Health insurance products are likely to
coverage in India is bound to grow overall insurance vehicles. Other recent require additional distribution channels
healthcare costs. This is the experience innovations such as accelerated payout on beyond the dominant agency force. Based
in nearly every developed country, where life insurance or reverse mortgages help on the U.S. experience, several innovations
healthcare costs have been growing at a with end-of-life care expenses. hold promise:
rapid rate for decades, for most years • Direct-response channels. These
Aligning the financial mechanisms with the
well in excess of aggregate inflation. In include a captive sales force, call
needs of diverse consumer segments
response, health insurers in other centres, the Internet, direct mail, and
improves financing efficiency. For
markets are developing new techniques television commercials. A leading U.S.
example, many consumers are unwilling to
to achieve better medical outcomes at player primarily uses the Internet, for
purchase long-term care insurance when
lower costs. A number of the tools example, to sell a product aimed at
they are young, as they view it as an
developed in that context, such as consumers aged 18 to 29 (“young
unnecessary expense. They are more
network tiering for consumers and invincibles”) who think they do not need
concerned about meeting mortgage
episode contracting for providers appear health insurance.
payments or saving for their children’s
relevant for an emerging market setting.
education while the threat of long-term • Retail stores. Health insurers in the U.S.
care seems distant. On the other hand, as are now offering health benefit products
Capabilities Required for Retail consumers age and recognise the need for through leading retail and pharmacy
Health Insurance long-term care coverage, they often find chains. One of the biggest success stories
Success in retailing health insurance in the premiums unaffordable or are denied for payers has been selling Medicare-
India will entail developing new coverage due to medical underwriting. related products to the elderly through
capabilities. These include most Products that combine savings features bricks-and-mortar retailers.
importantly product and channel with catastrophic coverage for younger • Affinity-marketing relationships.
innovation as well as risk-based families or the monetization of illiquid Health insurers have entered successful
underwriting. assets combined with health insurance at affinity partnerships with diverse players

issue focus
behaviour with actuarial science could and diabetes, which could be provided
create competitive advantage. For for and funded by the private sector
example, if actuaries could determine how • Tertiary prevention consists of ongoing
consumer behaviour would change a priori interventions aimed at decreasing or
WHO statistics and build that into product pricing rather delaying the severity and frequency of
indicate that 8 than wait for years to study observed recurrent events of chronic or episodic
million people die behaviour, they could benefit from diseases. Examples include family-
prematurely every substantive gains. Insurers in the U.S. have oriented disease management therapies
leveraged detailed data to build for cardio-vascular diseases, or disease
year in India from sophisticated actuarial models that are management programs for diabetes
diseases that are more powerful by a factor of over 1,000 patients, where again the private sector
relatively easily relative to competitors. can play an important role.
preventable, if WHO statistics indicate that 8 million
Insurance Coverage Beyond
certain primary people die prematurely every year in India
Hospitalization Benefits
preventive measures Private sector group and individual health
from diseases that are relatively easily
preventable, if certain primary preventive
were adopted by the insurance coverage in India today focuses
measures were adopted by the public
public authorities. on hospitalisation benefits with a limited
authorities.
sum assured. While this provides valuable
coverage, preventive care techniques are
Screening programs
important to improve medical outcomes A number of countries have recognized the
such as airlines and the American and to provide cost-effective health benefits of health insurance packages that
Association of Retired Persons (AARP). insurance. In India, there remains a huge cover not only acute, curative expenses
need for simple primary prevention that but also focus on secondary prevention
Different consumer segments have
largely falls into the public domain. measures, such as health screening. In
different preferences and attitudes, and
However, the private health insurance can Germany, for example, the statutory health
health insurers must understand them.
make important contributions at the insurance since 2002 covers 5 specific
Some consumers, for example, want a
secondary and tertiary prevention levels. programs including early cancer diagnosis,
trusted adviser who can make decisions for
preventive health check-ups, youth check-
them, while others desire information and
Primary vs Advanced Prevention ups, dental check-ups for children, and
tools to make their own decisions.
In assessing the cost-benefit equation of a check-ups and screening for children.
Preferences also vary by demographics; for
number of techniques and determining Private health insurers in Germany are
example, older people tend to like greater
who is best positioned to provide these complementing this statutory screening
support. Understanding such preferences
services it is helpful to distinguish between program. One of the leading German
is important in building the right channel
three levels of preventive care: private health insurers, for example, offers
architecture. Because a consumer’s risk
• Primary prevention entails reduction in a special tariff on prevention and
profile, i.e. health status is correlated to
the level of one or more identified macro screenings designed as supplementary non-
demographics, the choice of channels can
risk factors to reduce the probability of obligatory health insurance for Statutory
be a significant driver of understanding risk
the initial occurrence of a disease. Health Insurance members. Policies cover
and required pricing.
Examples include road safety, clean up to 27 different screenings (depending
water, food fortification and on age) that are not already covered and
Risk-based pricing
vaccinations, which are typically cost up to €20.50 per month.
Product and channel innovations alone are
not enough. Health insurers need to Government-led In India, based on our analysis of publicly
understand the risk profile of individuals • Secondary prevention aims at detecting available data, 3 million premature deaths
and their ability and willingness to pay, a disease at a very early stage to prevent could be avoided every year via secondary
which often varies by segment and or delay its progression. Examples prevention measures of this type, mostly
channel. Marrying insights into consumer include screening programs for cancer by screening for diabetes and malignant

issue focus
neoplasms. Secondary prevention studies suggest that the cost-benefit ratios incentives that stimulate provider and
measures for the top 10 diseases ranked are the highest and clearly positive for consumer-driven change. Over the long-
by cost-effectiveness could prevent or diseases like congestive heart failure, term, these “self-directed” approaches are
significantly delay 1.9 million premature asthma and potential diabetes. likely to accelerate as individuals assume
deaths in India per year. greater ownership and financial stake in
Techniques to Manage Medical their healthcare decisions and
Disease management programs Value transparency in provider performance
Disease management programs are for The combination of rising health awareness increases.
chronically ill patients and require patients and income levels, increased access to
“Self-directed” approaches appear well
to change their behavior and the way they insurance and broader coverage in India is
suited for retail-oriented emerging
interact with providers. In a number of bound to grow overall healthcare costs.
markets. In many of these markets,
countries such programs have been This is the experience of nearly every
consumers bear significant medical risk and
introduced by public and private health developed country, where healthcare costs
providers actively compete for patients.
insurers to improve medical outcomes and have been growing at a rapid rate for
Developing economies have the
to lower costs. Germany’s statutory health decades, for most years well in excess of
opportunity to leapfrog to deploying self-
insurance program covers more than 3 aggregate inflation.
directed approaches that would promote
million patients and six diseases – Type I In response, payors in large private health competition, innovation, and ultimately
and Type II diabetes, breast cancer, insurance markets such as the U.S. have better medical outcomes at lower costs
coronary heart disease, asthma and recently started taking a more integrated through appropriate stakeholder
chronically obstructive lung diseases. approach across the former siloed- incentives.
To make these programs successful, a functions of plan, design, network, claims,
number of incentives were created: and care management to maximize Influencing providers
medical value. Several of the techniques In a more “self-directed” model, providers
• Health funds receive additional
that they are employing could be beneficial are incentivized to optimize outcomes and
premium payments as financial
to players in emerging markets.
incentives for each patient enrolled in a
disease management program as part of
the industry-wide risk-balancing scheme;
Payor- vs Consumer or Provider-
directed approaches
these payments currently range from
Historically, the emphasis in medical value
€2,300 for asthma at the lower end and
management in the U.S. has been on
€6,700 for breast cancer at the higher
“payor-directed” approaches focused on
end of the spectrum
engaging providers (e.g., hospital
• Patients are given incentives through
utilisation review and case management).
Secondary prevention
lower co-payments and reduced
These approaches will continue to be measures for the top
premium payments important for the foreseeable future. 10 diseases ranked
• Providers get ongoing fee-for-service
However, a confluence of factors is leading by cost-effectiveness
compensation. In addition, there are
incentives to encourage enrolment and
to medical cost-control innovations that could prevent or
are more “self-directed” by providers and
process efficiency, for example, €20 for significantly delay 1.9
consumers: 1) the failure of payor-directed
consulting a patient and introducing
approaches alone to manage medical costs;
million premature
them to the program, or a €200 one-time
2) recognition of broad disparities in deaths in India per
payment for investments into electronic
data transmission from the physician’s
provider performance; 3) the increasing year.
proportion of chronic and discretionary
office to data centre.
care on total medical costs; and 4) new
The cost-benefit equation from a long- regulations and “ownership” mindsets.
term health insurance perspective is Given these factors, payors are
different by disease. A number of research supplementing traditional approaches with

issue focus
health and demographic factors (e.g., consumer awareness e.g., general health
co-morbidities, age, sex). A total care education, health club memberships,
cost estimate that is personalised to the health screenings, weight loss and
specific consumer and bundles smoking cessation programs. Shifting
treatment costs over multiple visits for focus from “sick care” to true “health
a given illness is the end-game for this care” with programs and benefits across
When consumers approach. the entire care continuum can minimise
have financial stake These “self-directed” provider approaches downstream costs.
in their healthcare shift incentives away from a fee-for-service Consumer-driven approaches have the
reimbursement model to one that is more
decisions, they seek opportunity to be implemented effectively
value-based. in emerging markets. These markets do not
more information on
have the legacy of healthcare paternalism
their expected Influencing consumers that characterizes many developed
liability in advance of For consumers too, the market is moving economies. In addition, more so than the
toward a more “self-directed” approach–
receiving care. “self-directed” provider approaches,
members are engaged and incentivized to consumer techniques do not rely on
make utilization, cost, and quality sophisticated medical management
decisions. Tools to influence consumer protocols. In fact, many of the core skill
behaviors include: sets to implement them could be leveraged
• Consumer decision support: Such tools from service vendors emerging in other
enable patients to make better geographies.
utilization through increased transparency healthcare decisions. When consumers
gained from quality information and have financial stake in their healthcare Conclusion
appropriate economic incentives. Tools to decisions, they seek more information India faces both the opportunity and
achieve this include: on their expected liability in advance of challenge to develop its own approach to
• Pay-for-performance: This involves receiving care. As tools emerge that expanding health insurance coverage in a
financial or other incentives to high- make the dispersion in provider pricing financially sustainable fashion.
performing providers at the hospital and more transparent, early evidence in the Experiences of various countries suggest
physician level. This tool requires US suggests consumers shift strongly to that India’s private health insurance sector
cooperation and agreement between the product that offers the highest can make significant contributions in a
payors and providers on the key perceived medical value largely retail-dominated market by
performance indicators that determine • Care networks/benefit tiering: By way tailoring their products to the needs of
compensation for physicians and of this approach, providers are tiered various consumer segments and by working
facilities. Initial experiments in place based upon efficiency/quality with healthcare providers to achieve
today are largely based on process information (at the hospital/physician higher-quality medical care in a cost
metrics (e.g., did the heart attack and procedure level), and patients are efficient manner.
patient receive an aspirin?) with true incentivized to seek to best-value
clinical outcomes-based metrics likely to providers. These care networks create
emerge in the future (e.g., what is the value based on performance outcomes
morbidity rate after a heart attack?). rather than simply seeking discounts in
• Episode contracting: In this case, exchange for patient volume and prompt
reimbursements are based on the payment
estimated total cost for an end-to-end • Wellness/lifestyle programs: This tool
set of expenses for a clinical condition. focuses on preventive and promotive
It typically includes all inpatient, measures. It directs members toward
outpatient, drug, and diagnostic healthier lifestyles to prevent the
The author is a Partner in McKinsey &
expenses and is risk-adjusted by several occurrence of disease through increased Company’s New Delhi office.

issue focus
Designing New
Health Insurance Products
TECHNICAL CONSIDERATIONS
RICHARD KIPP AND THOMAS SNOOK WRITE THAT IN ORDER TO BE MORE SUCCESSFUL IN THE AREA OF HEALTH INSURANCE,
INDIAN INSURERS HAVE TO CLASSIFY THE RISKS IN ACCORDANCE WITH THE INDIVIDUAL’S PROFILE AND PRICE THEM
ACCORDINGLY.
T
here are a number of new benefit certain outpatient services like preventive careful benefit design is crucial. Moral
structures that are being considered procedures and services. hazard is a concern. For example, an
for introduction into the Indian insurer will not want to offer a hospital
In each case, actuaries and other financial
health insurance market or that have cash benefit that covered more than the
professionals working for Indian insurers
recently been introduced into the market. expected patient out-of-pocket expenses
need data of some type to formulate an
Most of these have been developed by the during a hospital stay; otherwise the
approach to pricing new coverage where
insurers. Some have been developed at the patient would stay to gain financially by
no claims experience exists. Following are
encouragement of the IRDA. New benefits being in the hospital! The key here is not
some general observations about issues
mean insurers are taking new pricing risk, to create an incentive to such a degree
related to the benefits outlined above.
but there is little data available for the that it encourages hospital admissions,
current dominant benefit, Mediclaim; and Hospital Cash
virtually none for services not currently In the case of hospital cash benefits, the
covered by Mediclaim policies. This means actuary will need to tailor the pricing
insurers will need to proceed carefully as assumptions to the target populations Actuaries and other
new benefits are added. This paper being insured. Variables such as age,
discusses key factors that insurers will need gender, geographic location, occupation
financial
to consider when developing pricing. and income level are known to correlate professionals working
Among the service scope expansion ideas with hospital utilization and hence will be for Indian insurers
are (1) hospital cash, (2) critical illness, important considerations in pricing this need data of some
benefit. The cash benefit usually makes a
(3) elderly coverage, (4) comprehensive
payment to a person that is hospitalized
type to formulate an
inpatient and outpatient coverage and (5)
at some scheduled amount, typically on a approach to pricing
disease treatment policies. Other features
that are being considered are per day basis and usually is limited to 60- new coverage where
implementation of deductibles and
90 days of cover per hospitalization. no claims experience
Certain types of hospitalization stays are
copays/coinsurance as well as “inside” or
excluded for specific surgeries and
exists.
sub-limits on daily benefits for
hospitalizations that commence within 30
hospitalization, consultation fees, and ICU
days of policy issuance.
charges. Others talk in more specific terms
about expanding benefits to include As with all medical insurance policies,

issue focus
thus causing losses for the medical Plans for the Elderly and good underwriting are extremely
insurance plan and the hospital cash plan. These plans offer coverage to a group of important when this benefit is sold. The
people that were traditionally considered potential for adverse selection at issue is
Pricing the hospital cash benefit requires
a high risk group. The structure of the very great, and it is important that an
a sense of the expected number of
coverage is much like a Mediclaim policy insurer undertake the necessary efforts to
admissions in a given population and the
but with somewhat tighter limits on determine if an applicant already has one
expected length of the hospitalization.
Both are typically triggers that dictate the payment for treatment costs and lower sum of the covered diseases. Asymmetric
cash payout. Indian admission rates for the insured amounts. Special attention is paid information regarding a patient’s condition
Mediclaim population appear to be in the to diseases of the elderly in setting limits. would make offering these riders
5-7% range at this time and expected For example payment for treatment untenable. While these coverages are quite
lengths of stay per hospitalization in the prostate disease might have a separate common in private health insurance
5-8 day range. The cash benefit is often sub-limit. The expansion into this market markets around the world, it is not a widely
offered in tandem with a critical illness will have to be done carefully given that held benefit and little data exists to
rider to a life policy, but is also offered on the cost relativity for someone in the 60’s validate the assumptions regarding disease
a stand alone basis by some. This combined might be 4-6 times that of a 25 year old. probabilities. This alone justifies a
benefit could actually be used as a Recognition of that fact in the pricing and cautious approach to underwriting and
replacement for a Mediclaim policy. If you underwriting of these policies will make it pricing these benefits.
start with a Mediclaim policy and add sub- possible for insurers to venture into this
limits you can mimic a hospital cash market. In addition, products which have Disease Benefits
policy’s features. In pricing, though, you a significant co-pay are favored by insurers A variation on the critical illness rider
would also need to reflect any changes in when providing cover to the elderly. The offers coverage for the treatment of the
the target demographics for this policy co-pay encourages the policy holder to disease conditions as opposed to a cash
when compared to the Mediclaim shop for the most cost effective treatment payout if the diagnosis is present. Payment
insured base. as well as to scrutinize hospital bills, since is made under the terms of these policies
they are paying for a portion, usually 20%. only to indemnify the insured for the cost
By involving the policy holder in cost of treatments. As with the Critical Illness
sharing the insurer seeks to leverage the benefit, adverse selection is always of
policy holder’s abilities in managing cost great concern under these policies, and so
of treatment. Another alternative adopted offering these benefits requires skillful and
by insurers is to limit cashless coverage to expert underwriting.
a specific amount, say Rs.1 lac, and provide
Just as in the Critical Illness benefit, it is
additional cover in the form of a
The co-pay reimbursement benefit. This also involves
important to have some sense of the
prevalence and incidence of the covered
encourages the the policy holder in cost management as
diseases. The Indian incidence rates, for
policy holder to shop they are paying a component out of pocket
these diseases, are not well known,
for the most cost initially.
particularly in an insured population.
effective treatment Public health officials have made estimates
Critical Illness
as well as to Critical illness benefits are most commonly
for the overall population of the
prevalence of critical illnesses (see Table
scrutinize hospital sold by life insurers as riders to life policies.
1). Incidence of disease and the related
bills, since they are They are usually structured in a way which
treatments are of utmost interest to
pays a defined percentage of the policy
paying for a portion, insurers. The mere existence of a disease
amount in the event a policyholder is
usually 20%. diagnosed with one of several designated
in a population does not necessarily
translate into incidence of treatment at
critical illnesses. Some insurers are offering
any given point in time, given some people
these policies on a stand alone basis.
are asymptomatic and go from day to day
Precise definitions of the covered illnesses without using the healthcare system.

issue focus
these patients is achievable and If a terminal illness is involved, then

worthwhile. If a clinical management helping to arrange for hospice or other end-
approach is used, the overall cost of the of -life support may also help to provide
Covering all case may be reduced. Such is the case with more efficient and appropriate care to
outpatient the Diabetes benefit currently being covered individuals.
offered by Star in Chennai. Diabetes lends
expenses in
itself nicely to a case management Outpatient Benefits
addition to approach. Inclusion of non-inpatient benefits is an
inpatient
expenses would
Table 1- CRITICAL ILLNESS PREVALENCE
be a huge
broadening of the Per 1000
scope of policy Disease Name India US
benefits and
Cancer 0.945 0.439
would represent a Coronary Artery Disease 4.000 48.500
major shift in the Cardiac Valve Replacement 1.156 Very low
philosophy of Major Organ Failure and Related Transplant Surgeries Very low 0.000
Stroke and Paralysis 2.030 16.949
health insurance Cardiac Valve Replacement (rheumatic heart disease) 1.156 Very low
in India. Renal Failure 7.852 1.443
Multiple Sclerosis Very low 1.429
Source: Various sources including Centre for Community Medicine, All India Institute of Medical
Sciences, New Delhi, India. ammu@ndb.vsnl.net.in and the World Health Organization.
However, since most of the typical diseases interesting issue in the Indian context. additional care must be taken when
covered by these policies (i.e., cancer, Historically, Mediclaim has covered only underwriting and pricing the policy.
cardiac failure, myocardial infarction, inpatient facility and professional claims Experience in other markets around the
kidney failure, major organ failure and along with some of the pre-admission and world shows that such policies can be
related transplant surgeries, stroke, post admission expenses. Covering all overused or used for illnesses that could
paralysis, coronary artery disease and outpatient expenses in addition to have (and would have in the absence of
related bypass graft surgery, cardiac valve inpatient expenses would be a huge insurance) been self-treated or financed
replacement and multiple sclerosis) involve broadening of the scope of policy benefits out of pocket. Even younger, healthier
hospitalizations at some point during the and would represent a major shift in the policyholders are likely to avail themselves
course of treatment, current Mediclaim philosophy of health insurance in India. of the services covered under these
and other Indian insurance data could be Those companies in India that have policies.
used to develop estimates of incidence experimented with such policy broadening
rates. Using that information and actuarial have experienced huge increases in claim Pricing Expanded Health Services
judgment, reasonable prices can be volumes and the associated administrative There are many pricing considerations for
assigned to these policies. expenses. To this point, the focus has been expanded health benefits. They include:
One important policy structure issue is on offering policies which protect the • the diagnoses covered
whether to sell these policies on a sum policyholder from costly care that might
• the procedures covered
insured basis as is Mediclaim, or on some threaten a person’s financial security. This
• the service area of the policyholder(s)
other basis. Additionally, it will be essential has been done with an indemnity policy
for the insurers to consider whether case that has a sum insured cap on the insurer’s • provider fees for services rendered and
management or disease management of liability. If outpatient services are covered, cost sharing with the policyholder

issue focus
• underwriting and risk assessment In Tables 2, 3 and 4, we show purely to provide an unlimited payment for most
processes used illustrative costs for the various service health care costs, you can see that by
• whether it is a large group, small group types and utilization rates that reflect very adding the new benefits you would nearly
or individual policy approximate expectations of usage for quadruple the cost of coverage.
inpatient and outpatient services. These
• the place the service is rendered Looking at the Table, one can see that
data are not intended to be used as a basis
• new claim volumes and the associated inpatient facility costs represent about 20%
for rating and are shown only to illustrate
cost of processing of the overall cost of these benefits. This
the data that is needed, and how it is
is important because these are the primary
• pre-submission review and management typically used in an actuarial analysis.
costs covered, along with a portion of what
of the claim When rating an actual insurance product,
is shown here as physician cost, by
an insurer should carefully develop
Naturally, data and a general rating model Mediclaim policies in India today. Together
assumption values which reflect their own
will be needed to estimate the rates for a these costs combined might be about 30%
policies’ benefit levels and negotiated
given policy. The basic formula for of total potential costs. Expanding benefits
costs with their providers, along with their
calculating the claim cost component of a as illustrated here will greatly increase
best estimates of the impact of all of the
policy rate is: both the cost to policyholders and the
rating factors mentioned above.
insurer’s exposure to risk. Consequently,
Cost per service x Number of services
Imagining for the sake of illustration that insurers will want to introduce policyholder
per policyholder = Cost per policy for
the costs in Table 2 are roughly cost sharing along with inside limits on the
some unit of time (usually a month or
representative of an Indian insurer’s costs payout for some of the expanded benefits
year).
The statistics – cost per service and number

of services – can be greatly influenced by
the pricing considerations mentioned Table 2- ILLUSTRATIVE COST OF BENEFITS BY TYPE OF SERVICE
above. For example, it is not uncommon
to see hospital inpatient utilization rates Type of Cost per Services per Annual Cost Cost Per
vary by 50% or more among geographic Service Unit Service Policyholder per Policy- Month
regions of the same state. Hospital INR INR
Typically, the starting costs for developing Inpatient Admission 50000 0.06 3000 250
a company’s internal tariff rates would be
Outpatient Case 900 1.20 1080 90
organized by types of service as shown
below in Table 2. Table 2 is a very basic Total Facility 4080 340
and simplified example of an “actuarial Physician

cost model”, of the sort the actuary uses Visits 400 5 2000 167
to price health insurance benefits. The Procedures 4000 0.7 2800 233
types of service shown are separated into
Tests 750 7 5250 437.5
three broad categories first. They are
Facility, Physician and Other. The Facility Total
costs are simply the costs for the use of Physician 10050 837.5
the facilities such as room and board for Other
inpatient and emergency or outpatient Pharmacy Script 75 20 1500 125
surgical suite for example. Physician
DME 1200 0.1 120 10
charges are for any service or procedure
ordered or performed by a physician. The Glasses 500 0.2 100 8
other category would be a collection of Other 200 0.2 40 3
everything else and might include such Total Other 1760 147
services as pharmaceuticals or medical Grand Total 15890 1324
devices.

issue focus
as the new benefits are introduced into maximums on expected policy claims cost. distribution to model the cost of an INR
the market. Pricing such cost sharing In addition to modeling the impact of 20000 sum-insured policy that covers a full
requires another, different actuarial tool benefit changes one must deal with the scope of services. The pure benefit
called a “claims probability distribution”. other rating factors mentioned above. For difference between the theoretical full
example the underwriter must account for benefit cost of INR 15,890 and the INR
In the Table that follows, we present an
the difference in benefit usage between a 20,000 benefit cost of INR 9,250 is about
example of a claims probability distribution
person that has an INR 20,000 sum-insured 40%. This measures only the difference in
(CPD). The Table shows, for various
and a 5 lac sum-insured. Benefit usage expected costs attributable to the benefit
categories of claim size, the probability
would likely be somewhat more cap under equal utilization rates. The
of a claim of a given size and the average
conservative under the lower benefit as expected costs would be further reduced
cost of those claims. This distribution is
the insured individual must be more by a factor of 10-15% to reflect the impact
intended to represent the full benefit
conscious of his benefit utilization than the of the lower benefit maximum in reducing
potential cost of claims with no policy-
individual with the larger policy. benefit utilization rates. In this way, the
holder cost sharing, as there would be with
a Mediclaim policy. This CPD can then be Table 4 is an illustrative Mediclaim pricing actuary can develop an expected claim
used to calculate the impact of for a very low benefit level. It shows how cost for use in the insurer’s rate
deductibles, coinsurance and sum-insured one might use the claim probability calculations.
The pricing shown in Tables 2, 3, and 4 is a

very important scheme for insurers to
become familiar with. Compiling the
Table 3- ILLUSTRATIVE CLAIM PROBABILITY DISTRIBUTION
necessary data to analyze costs for the new
INR Range Average Cost % of Cost per Policy Cost per Policy services will be challenging. Creating a
per Claim Claims per Annum per Month model of those costs which can be tested
0 0 35.00% 0 0 and improved as experience emerges will
1-5000 4000 10.00% 400 33 be crucial for the industry success in the
5001 - 10000 7800 10.00% 780 65
Indian health insurance market over the
10001 - 15000 12800 10.00% 1280 107
long term.
15001 - 20000 17900 10.00% 1790 149
20001 - 25000 22900 10.00% 2290 191
25001 - 30000 28500 10.00% 2850 238 Potential Impact on Trends
30001 + 130000 5.00% 6500 542 A thorough and comprehensive analysis of
Average 24446 100.00% 15890 1324 claim cost trends is vital to the health
insurance pricing process. Trend analysis
typically combines a review of historical
experience over some time period along
with a consideration of the factors that
may cause costs to change going forward.
Table 4- PRICING A INR 20,000 INR SUM-INSURED POLICY In a market with new, broader benefits
INR Range Average Cost % of Cost per Policy Cost per Policy being frequently introduced, it will be
per Claim Claims per Annum per Month extremely important to parse the historical
0 0 35.00% 0 0 data into homogeneous sub-classes to
1-5000 4000 10.00% 400 33 understand the drivers of change.
5001 - 10000 7800 10.00% 780 65
For example, consider three years of claims
10001 - 15000 12800 10.00% 1280 107
costs data, in which the underlying benefit
15001 - 20000 17900 10.00% 1790 149
mix includes various proportion of the
20001 - 25000 20000 10.00% 2000 167
25001 - 30000 20000 10.00% 2000 167 following benefits:
30001 + 20000 5.00% 1000 83 • Hospital Inpatient and Outpatient Only (H)
Average 14231 100.00% 9250 771 • Hospital plus Physician (H+P)

issue focus
• Hospital plus Physician and Other and 10% Other. Let’s assume further for Historical experience over the years in
(H+P+O) the sake of simplicity that there is no other markets shows that, absent any other
underlying cost trend. As illustrated in controls, enrollees with richer benefits will
Let’s say for this example that in Year 1,
Table 5 below, any analysis that is done exhibit higher utilization rates than those
the enrollment was 100% in Hospital Only
using total cost in aggregate across all with less rich benefits. This phenomenon
benefits, Year 2 the enrollment mix was
benefits (without segregating claims into (commonly called “induced utilization”)
80% Hospital Only and 20% Hospital plus
benefit categories) will show that there will affect the trends that are developed
Physician and in year 3 the mix was 70%
was an apparent trend. from historical data, since higher
Hospital Only, 20% Hospital plus Physician
utilization rates will result in higher claim
In the example shown above, we calculate
cost trends. Having a good data
management and analysis capability will
Table 5 - ENROLLMENT % AND COST BY YEAR be essential in the coming months and
years. This capability has not been
Monthly Costs
universally held by all insurers in the past,
Year 1 Year 2 Year 3 By Benefit Type
although many improvements have been
from Table 2
made in the quality of the data being
H 100% 80% 70% 340 captured and in the reporting of that data
H+P 0% 20% 20% 1177.5 by some.
H+P+O 0% 0% 10% 1324
Weighted Average Cost 340 506 606
Underwriting Tools for the New
Benefits
Apparent Trend 506/340 606/506
We have identified two key components
Percent Increase - 49% 20%
necessary to successfully introduce
expanded benefits into the Indian health
insurance market: the ability to model
expected costs, and the ability to track
Weighted Average Cost by multiplying the claims experience and trends by
monthly costs by benefit type by the homogeneous groupings as it emerges. The
third and final component presented in this
Having a good data percentage of the population holding that
benefit type. For example: .8 x 340 + .2 x paper is the ability to identify, classify and
management and 1177.5 = 506. select risks to be insured.
analysis capability Today, Indian insurers are using medical
So, from the example, we see a 49% growth
will be essential in trend from Year 1 to Year 2, but this trend information to a limited extent to
the coming months is wholly attributable to the expansion of underwrite individuals and small groups.
and years. This additional benefits to 20% of the insured The most often used tool for managing risk
population. The actual underlying selection is the denial of claims for pre-
capability has not existing conditions. While effective, this
(secular) trend in the example is 0%. While
been universally held this is an exaggerated example to illustrate approach has caused much concern in the
by all insurers in the the concept, it will nonetheless be market because of poor communication
past, although many extremely important for an insurer to be and buyer expectations. A person buying
a policy may not know if a future medical
improvements have able to differentiate and categorize data
into meaningful groups to enable service will be covered.
been made in the appropriate analysis. The current definition of a pre-existing
quality of the data condition subject to exclusion in India is
In addition to the data analysis issue,
being captured and enrollees in these broader benefits will any condition that would have been
in the reporting of most likely behave very differently than present at the time of policy purchase,
that data by some. those that held the Mediclaim policy. even if the patient was asymptomatic at

issue focus
that time and did not know they had the insurer via the application form. A risk to the individual that would translate into
problem. This is considerably more onerous score is assigned based on specific medical a rate or benefit adjustment, or that would
than the definition used in other countries, conditions and other criteria present in the indicate the individual be declined
where the definition of a pre-existing applicant. An insurer will use an analytical coverage.
condition is based on the time between tool, or “underwriting guideline” to
last treatment and the new claim. If that develop an estimate of the impact that Aneurysm
period is 12 months, or longer, the medical condition will have on future claim A sac formed by the dilatation of the wall
condition is not considered pre-existing. costs. of an artery or the heart. The causative
In some policies there is a 3-, 6-, or 12- reason may be congenital, (e.g., anterior
Below we show a sample underwriting
month “look back” from the enrollment cerebral artery), traumatic (e.g., popliteal
guideline for aneurysm. It requires a series
date to establish if a diagnosis or treatment in a football player), or diseaserelated,
of questions be asked and answered about
had been given. Under a look-back (e.g., cardiac aneurysm).
the course of the problem and the patient’s
provision, a condition must have been
current symptoms. Armed with this In Table 6, you see first the medical
diagnosed or treated within the look-back
information a risk score can be assigned definition of an aneurysm, followed by a
period to be considered pre-existing for
purposes of the coverage exclusion.
Additionally, usually there is no more than
Table 6 – RISK CLASSIFICATION USING DEBITS TO REFLECT FUTURE COSTS
a 12-month exclusion after policy issue for
Elapsed Debit Debit
future treatments relating to conditions
Time Points Riders Points
that are found in the look-back period.
w/ Riders
If pre-existing condition exclusions are to
be brought more in line with the global Development
standard, this will make the exclusions less
1. Age at onset
effective at controlling risk. As a result,
2. Symptoms
Indian insurers will need to do more
effective medical underwriting to classify 3. What vessel is involved?
the risk of an individual or group. Is the heart involved?
Classifying risk allows an insurer to charge 4. Etiology
an appropriate premium rate, devise an
5. Hemorrhage?
appropriate benefit structure, or in certain
cases decline to issue coverage to risks it
Rating
believes are uninsurable. To do this,
Cerebral artery (“berry”) 500
medical data will have to be easily
Unoperated <2 years 100
captured and translated into risk scores
Operated >2 years 15
that measure the morbidity level of an
individual or group relative to the insurer’s
Aortic, abdominal, thoracic 500
entire book of business or some other
Unoperated <2 years 175
norm.
Operated >2 years 125
The development of a risk score
methodology is a complex task to which Peripheral artery 200
insurers and other experts have devoted a Unoperated <1 year 75
great deal of time, thought and research. Operated 13 years 35
One approach (common for individual and >3 years STD
small group coverage, but not common for
larger employer coverage) is to conduct Cardiac or ventricular SA+100
an analysis of the medical history and
conditions that become known to the Source: Milliman Medical Underwriting Guidelines (MUGs)

issue focus
since onset. For each, the guidelines assign industry by protecting insurers from
“Debit Points”, the analytical score which adverse selection and bad pricing
In a growing indicates the relative risk of the individual decisions. Investing in the creation of
market, it will be to the insurer. In the Table, “STD” means actuarial pricing models and accumulating
important to the person has achieved the same risk score and analyzing data to help inform the
as a “standard” person. “SA” means process of benefit expansion will save the
systematize and
symptom of another condition. insurance industry several lakhs of rupees
automate the data over the short and long term. Creating
A complete set of underwriting guidelines
collection and risk disciplined, objective, and to the extent
will include underwriting considerations
scoring process as possible, automated processes to assist the
and debit points assigned for hundreds of
much as possible. the most common and significant medical
actuarial and underwriting functions in
Additionally, the conditions. Only then will the tool be able
advance of the new health benefits will
be the key to long term success.
risk score assigned to provide enough guidance to the
to an individual underwriters to protect the insurer from a
must be translated wide range of potential risks and for them

to deal with risk classification in a
in a well-defined,
systematic way.
objective, and
In a growing market, it will be important
formulaic way into
to systematize and automate the data
the rate or benefit collection and risk scoring process as much
decision for that as possible. Additionally, the risk score
policy. assigned to an individual must be
translated in a well-defined, objective, and
formulaic way into the rate or benefit
decision for that policy. Typically such
formulas are designed by an insurer’s
actuary working in conjunction with
set of questions that an underwriter should underwriting staff.
use to gather sufficient information
regarding an applicant who has indicated Conclusion
that he/she has had an aneurysm in the The expansion and liberalization of
past. A trained, experienced underwriter medical and health related benefits seem
Richard Kipp is the Managing Director of
can use this information to assess the risk inevitable in the Indian market. Actuaries
Milliman in India and can be reached at
to the insurer of enrolling the applicant. and underwriters will play an important richard.kipp@milliman.com. Tom Snook is a
principal with the Phoenix, USA office of
Following those questions are a list of role ensuring the ongoing solvency and
Milliman and can be contacted at
specific types of aneurysm and their time financial capacity of the health insurance tom.snook@milliman.com.

issue focus
Health Security for All

GOVERNMENT INITIATIVES IN HEALTH INSURANCE
DR. SOMIL NAGPAL, DR. N DEVADASAN AND NEHAL JAIN NARRATE THE DETAILS OF THE VARIOUS GOVERNMENT SCHEMES
IN HEALTHCARE PROTECTION – SOME OF WHICH HAVE BEEN SUCCESSFUL AND OTHERS NOT SO. THEY OPINE THAT THE
INITIATIVES WHICH PARTICULARLY ADDRESS THE HEALTH NEEDS OF THE VULNERABLE GROUPS ARE ESSENTIAL FOR A
MORE WIDESPREAD FORM OF HEALTH SECURITY.
Introduction and medical benefits to its members. It has been recording a sizeable surplus every
T
his article attempts to trace the covers about 35.5 million beneficiaries, year, which has been linked to the
recent government initiatives, by which includes workers employed in the contributions by higher paid workers,
central, state and local government formal sector and their dependents, in currently those drawing up to Rs.10,000
bodies, in providing health insurance organizations which meet certain criteria per month.
coverage within their respective in terms of size of the unit and the wages
jurisdictions. The paper also briefly of the workers. ESIS provides for
touches upon the widely recognized comprehensive health services through a
government-mandated schemes - CGHS network of its own dispensaries and
hospitals, and the network is supplemented
and ESIS - targeted at the government ESIS provides for
employees and the formal sector by Authorized Medical Attendants and
comprehensive
respectively; and then moves on to discuss private hospitals as per need.
health services
schemes with more inclusive coverage, The coverage includes OPD and IPD
including those aimed at rural and poor
through a network of
services, and a variety of cash benefits to
households. compensate for loss of pay and other
its own dispensaries
eventualities. The scheme is financed by and hospitals, and
Employees’ State Insurance a contribution from employers, employees the network is
Scheme (ESIS)1 and by the central and state governments. supplemented by
Formal systems for Health Insurance and The contribution by employers and Authorized Medical
health related social security in India began employees is the largest source for finance,
Attendants and
with the inception of the Employees’ State which in turn is a defined percentage of
Insurance Scheme, introduced vide the ESI
private hospitals as
the wages of the employees. Of late, the
Act, 1948, which provides for both cash ESI Corporation managing the ESI scheme
per need.
1 Internet. http://esic.nic.in accessed on 12th December 2007.

issue focus
Outpatient care is provided through CGHS government to promote and subsidize an

dispensaries located in major cities. It also affordable health insurance product. The
uses the facilities of the government and UHIS also provided a useful model for many
approved private hospitals to provide subsequent state government and
inpatient care and reimburses the expenses community initiatives in health insurance
The UHIS also to the patient or the hospital, as the case to build upon.
provided a useful may be.
model for many Enabling Provisions in National
subsequent state Universal Health Insurance Rural Health Mission (NRHM)4
government and Scheme (UHIS)3 In 2006, the Ministry of Health and Family
It was in 2003 that the Ministry of Finance Welfare published a Framework for
community initiatives
announced, with ambitious targets, the developing Health Insurance programs,
in health insurance rolling out of a new health insurance under the umbrella of the National Rural
to build upon. scheme to address the needs of all sections Health Mission (NRHM) which stated that
of the society. The scheme was named the in addition to strengthening public health
Universal Health Insurance Scheme, and facilities, health insurance would also be
was implemented through the four public used to remove financing barriers and
sector general insurance companies. The improve access to healthcare, for financial
policy, which was modeled on the existing protection and to improve quality of
‘Mediclaim’ health insurance product, healthcare. The framework also clearly laid
Central Government Health
provided reimbursement of hospitalisation down certain pre-requisites for such
Scheme (CGHS)
expenses up to Rs.30,000/- to an individual government subsidized health insurance
CGHS was introduced in 1954 and is a
or as a floater over his family (subject to schemes and made a provision for
contributory health scheme providing
certain sub-limits on bed costs, surgeon/ subsidizing such health insurance
comprehensive medical care to the central
anesthetist fee, any one illness etc.), in initiatives undertaken by the states, within
government employees and their families
addition to some personal accident and the NRHM framework.
- both serving and retired, Members of
disability cover. The premium of Rs 365 per
Parliament, Supreme Court and High Court Some states have already proposed and
person and Rs 545 per family was
judges; and certain other categories of even initiated health insurance schemes
subsidized for those below the poverty
beneficiaries 2. CGHS has over 44 lakh with funding support from Government of
line, and the net premium for this group,
beneficiaries, and is financed largely by India under this NRHM framework. In other
after subsidies, is presently Rs 165 per
the Government of India budget, while the cases, certain schemes have been initiated
individual and Rs 245 for a family of 5.
government employees also contribute a by states and local government bodies from
nominal amount (currently ranging from The scheme, however, remained far from within their own resources also.
Rs 15 to Rs 150 per month) from their universal, and the enrolled numbers were Increasingly, there is willingness and
salaries based on their scale of pay. The a miniscule fraction of the target support available from the government to
coverage is comprehensive and includes population. The scheme was, however, make financial protection through the
both outpatient care and hospitalization. significant in its intent - that of the union health insurance mechanism more widely
2 Internet. http://mohfw.nic.in/cghs.htm accessed on 11th December 2007

3 Govt of India. Budget documents for 2003-04. Also based on information at websites of the public sector insurance companies.
4 Internet. www.mohfw.nic.in/NRHM/Documents/framework_for_health_insurance.pdf accessed on 13th Dec 2007

issue focus
available. Some such schemes are Sanjivni Scheme, Punjab and the insurance company are involved
discussed in more detail below. The government of Punjab launched the in negotiating a new premium, but in the
Sanjivni health care scheme for members meantime, the scheme has been
Critical Illness and Personal of rural cooperatives in Punjab in April discontinued.
Accident Scheme, Assam5 2006. For this an independent Sanjivni
This is a combined critical illness indemnity Trust was set up which managed the entire Kudumbashree, Kerala
cover for specified diseases (sum insured scheme. All members of the cooperative The Comprehensive health insurance
of Rs 25,000) along with an accidental societies in the state were eligible to enroll scheme for BPL families was developed by
death and disability cover (sum insured of for this scheme and the enrolment unit was the Government of Kerala, specifically its
Rs 50,000), fully paid for by the the family. The premium was Rs 400 per Kudumbashree unit. These neighbourhood
Government of Assam. The policy covers family and it covered all surgical treatment units were a well organized group of BPL
the entire electorate of the state along up to Rs.2 lakh per family. Deliveries were women who were the recipients of various
with their dependents, of ages 3 years to also covered up to Rs 10,000 per delivery government development programmes.
80 years, barring government employees and Rs 25,000 per family. Patients had to The Kerala government planned to
and those earning more than Rs 2 lakhs a use empanelled hospitals only. The Sanjivni introduce health insurance for these
year, which means about 30 million people. trust had empanelled all the government women and their families in order to
The scheme, designated Mukhyamantri’r hospitals in the state as well as 307 private protect them from high medical expenses
Jibon Jyoti Bima Achoni is implemented hospitals. The empanelment criterion was and resultant impoverishment.
through Revenue Circle Officers of the based on infrastructure, and there was no They attempted to improve on the design
state who receive and scrutinize claims and conspicuous attempt at cost control of the Universal Health Insurance scheme
pass them on to the insurer for mechanisms. A TPA was employed to (UHIS) and planned to also cover pre-
reimbursement. Against a premium of administer the scheme and provide existing diseases, maternity and mental
Rs.25 crore (including tax), the claims paid cashless services and a large private illness, while minimizing exclusions. They
during Aug 2005 to July 2006 amounted to insurance company was the insurer of this also added additional benefits like personal
6
Rs.9 crore for over 4,200 claimants . scheme. accident cover (up to Rs. One lakh) as well
as bystander allowance (Rs 50 per day up
In the first year (April 2006 – March 2007),
to a maximum of Rs 350) and domiciliary
2 lakh families (out of 18 lakh cooperative
hospitalization (up to Rs 6000) as part of
members) joined this scheme. The
the package design.
premium collected was Rs.8 crore.
An independent Unfortunately, because of the lack of cost A large private insurer was willing to insure
Sanjivni Trust was control measures in the design of the this product and also quoted a premium
set up which scheme, the claim experience of the of Rs 399. The government of Kerala
managed the entire scheme was very adverse, and planned to raise this premium from various
scheme. All approximately 5384 claims amounting to sources and would itself pay Rs 33 per
Rs.35 crore were made in the first year family covered, and requested the local
members of the
itself. This high claims ratio was a major governments to pay another Rs 33 while
cooperative setback to the scheme. The Sanjivni trust each family in turn was also to pay Rs 33.
societies in the
state were eligible
to enroll for this
scheme and the
enrolment unit was 5 Government of Assam, Planning and Development department. Guidelines for Mukhyamantri’r Jibon
Jyoti Bima Achoni 2005-06. Aug 2005.
the family. 6 Internet. Policy Reforms Options Database, India available at http://www.cbhi-hsprod.nic.in/ret.asp
accessed on 12th December 2007.

issue focus
The rest Rs 300 was supposed to come from any additional costs are payable by the
the Government of India – which was insured. Thus, to minimize his own
expected to be agreed upon on the same expenditure, the beneficiary would need
lines as the Ministry of Finance’s subsidy to avail of services in charitable or medical
to the UHIS. college hospitals. The scheme has thus
The members
been able to demonstrate viability even
The local government’s and the families’ getting hospitalized at this pricing of the premium and the
contribution was collected through the
are required to pay claim ratios have been well under control.
Kudumbashree mechanism. About 16 lakh
members were enrolled by paying their
a deductible of Rs And while there are logistics and other
contribution of Rs 33. However, as the 500 per issues which need to be streamlined
largest planned source of funds, the hospitalization, further, the scheme has demonstrated that
even a local government can garner
Government of India, refused to pay Rs 300 which is taken in
resources for health security of its
as subsidy (largely because the scheme was the corpus of IMC
a modified one and not the UHIS, which vulnerable groups.
to partially pay for
also meant the insurer was a private
the next year’s Rajasthan Swasthya Bima Yojana
insurance company and not a public sector
insurance company as was the case in
insurance. The Government of Rajasthan has very
UHIS), this scheme did not take off and is recently launched the Rajasthan Swasthya
yet to see the light of the day. Bima Yojana on 8th December 2007 after
months of intensive planning and
Senior Citizens Health Insurance preparation to design a patient friendly
Scheme, Indore Municipal product. All BPL families in the five pilot
Corporation7 districts of Rajasthan are covered under
and is presently in its fifth year. Services this scheme. The premium of Rs 480 is
Pandit Deendayal Upadhyaya Senior Citizen
are available through a network of partly paid by the Government of India (Rs
Health Insurance Scheme of Indore
hospitals in Indore, administered by a TPA, 300) and the Government of Rajasthan (Rs
Municipal Corporation (IMC) is a group
and cashless services are available in 180). The State Insurance & GPF Dept is
health insurance scheme, which is fully
network hospitals up to the specified sub- the insurer for the scheme. Patients can
funded by the corporation and is made
limit. The premium paid by IMC for 2007- go to either private or public providers to
available free of cost to the senior citizens
08 is Rs 395 per beneficiary, including taxes access hospital care. The sum assured for
between 60-80 years residing in Indore city.
and TPA costs. The members getting general illnesses is Rs 30,000 per family
The scheme covers hospitalization for a
hospitalized are required to pay a while for critical illnesses it is Rs 1.35 lakhs
sum insured of Rs 20,000, with sub-limits
deductible of Rs 500 per hospitalization, per family per year. Additionally, the
of Rs 4000, 7000 and 12000 based on the
which is taken in the corpus of IMC to
nature of hospitalization (conservative, insurance includes provision for diet of
partially pay for the next year’s insurance.
minor surgery or major surgery patient at the facility and transport cost
respectively) and with coverage for all pre- Since the amount of reimbursement to the is covered up to Rs 100 per hospitalization.
existing diseases and no first-year hospital or the individual is fixed, it serves Pre and post hospitalization expenses are
exclusions. The scheme began in 2003-04 as a strong incentive to control costs, as also covered. Hospitals are in the process
7 IRDA. Report of the Committee on Health Insurance for Senior Citizens. IRDA, Nov 2007.

issue focus
of being empanelled and a Standard willing to accept the tariff plan as proposed providing health security to their people.
treatment guidelines as well as a fixed by the insurance company. Thus, while publicly funded health systems
tariff plan for more than 700 procedures have been created and have their own
While the owner of this scheme is the state
have been made as cost control importance in the system, there is
government, there is a considerable
mechanisms. certainly a role for plugging in many access
premium subsidy (up to 75%) by the central
issues through the mechanism of health
The Medicare Relief Societies (a.k.a. Rogi government. There has been much back
insurance.
Kalyan Samitis) will administer the scheme end work done already to ensure that this
in the public hospitals, while a selected scheme is operational on April 1st 2008. It is access issues which play an important
TPA will do so at the Private hospital level. role in the utilization of benefits offered
The remaining districts are planned to be Lessons Learnt and the Road by health insurance. Thus, if a poor rural
covered in a phased manner based on the Ahead family is covered against hospitalization,
implementation experience. The above discussion and illustrative but the nearest eligible hospital is too far
examples of government initiated health or if the family is expected to pay first
The Rashtriya Swasthya Bima insurance schemes makes it evident that and seek reimbursement later, such factors
Yojana (RSBY) there is certainly a growing interest in act as a strong deterrent against utilization
This is the most recent health insurance central, state and local governments to of healthcare even when it is essential.
scheme from the Government of India’s explore alternative mechanisms for On the other hand, proximity to services,
stable. It plans to cover all the BPL families nil or low co-payments and low opportunity
in the country in a phased manner, and is costs of seeking care, availability of
implemented by the Ministry of Labour. In cashless facility etc are factors which can
the initial year (2008 – 2009), 120 districts drive up utilization and even lead to over-
are being covered by this scheme in 28 utilization.
states. An insurance company will be
The examples above also illustrate the
selected by the states based on open While publicly
importance of careful designing of any
bidding and will both insure as well as funded health
administer the scheme. The BPL family (up health insurance product before
systems have implementing the same, particularly in
to a maximum of 5 members) can enroll
by paying Rs 30 as registration fee. In
been created respect of providing checks and balances
return they will be given a smart card that and have their for adverse selection (in cases where the
has their photograph, as well as their own importance coverage is voluntary), cost escalation,
family details and thumb print impression. in the system, moral hazard and malpractices, which
need to be carefully addressed as much at
The BPL patient can avail services from there is certainly
the design stage as through subsequent
empanelled private hospital after a role for monitoring and modifications of the
validating his identification through the plugging in scheme. Indeed, a scheme which does not
smart card. The smart card also debits his
many access continue for long could shake the
account for the expenses incurred and will
inform the insurance company about this
issues through confidence of the target beneficiaries in
pending claim. If the insurance company the mechanism the health insurance system and could be
detrimental to the health system and to
accepts the claim, then the financial of health
health insurance. Similarly, as health
transaction is done through a transfer insurance. insurance influences the behaviour of
of funds.
insured persons as well as providers, it
Both private and public hospitals will be could be used as a means to improve access
reimbursed by this scheme, provided that and to encourage availability of services.
they have the prescribed facilities and are However, on the other hand, a poorly

issue focus
or overutilization of the benefits; and on agency. The RSBY is hoping that the smart
the other hand, clauses in insurance covers card will reduce the need for
which provide for refund/ discounts in administration, and we wait with bated
The other premium for very favourable claim breath to see the initial implementation
experience, are perhaps both necessary for experience.
important area
long-term sustainability of these health
that needs to be In the final analysis, while the ideal of a
security measures. This could include,
addressed by among others, careful negotiation and
universal health insurance system may still
be a far way off, these initiatives which
future schemes contracting with providers to ensure
particularly address the health needs of
launched by the quality, access and affordability.
the vulnerable groups are certainly
government is the Another key area to derive maximal welcome and could indeed pave the way
importance of a benefits from mass health insurance for a future, more widespread form of
formal mechanism schemes purchased by governments is to health security. There are lessons to be
or structure to ensure adequate awareness amongst the learnt from each scheme, and if those
beneficiaries who stand covered. While the lessons are indeed learnt and utilized, the
take ownership of
ideal way to ensure awareness of such a government interventions in ensuring
the scheme, scheme could well be collecting a health security for all would indeed be far
perhaps even to contribution in the premium, even if it is more consequential and useful for the
administer the a small amount, the administrative costs health system.
scheme. of such collection of small amounts have
to be kept in mind. Also, some government
schemes have been launched based on
enrolment - where the beneficiary fills in
a form, and so becomes aware that he is
part of such a scheme. However, in many
designed product could lead to cost
cases, premiums are paid by the
escalations and may take healthcare out
government as a lump sum amount or
of the reach of the uninsured and also lead
deducted by a co-operative from its
to a heavy social burden for meeting costs
member’s account, and the intended
of healthcare.
beneficiary may never even be aware of
While many states did enlist their public his being part of a health insurance
facilities as providers for their health scheme. This naturally impacts utilization,
insurance schemes, perhaps greater initial and claim ratios in initial periods remain
efforts would be needed to provide a level low.
playing field to the public/ government
The other important area that needs to be
hospitals- which could include, for
addressed by future schemes launched by
example, co-payments for using private
the government is the importance of a
hospitals, or alternative remuneration
formal mechanism or structure to take
mechanisms for public sector facilities, so
ownership of the scheme, perhaps even to
that utilization of public health Dr. Somil Nagpal is Special Officer-Health
administer the scheme. It is not enough to
infrastructure also improves along with Insurance, IRDA. Dr N Devadasan and Ms
design a good product, but it is also Nehal Jain are with the Institute of Public
improvement in access for the citizens. Health, Bangalore. Views expressed by the
important to govern and monitor it closely.
authors are in their personal capacity and do
Cost control mechanisms in the design of The UHIS was one such scheme that was not reflect the organizations with which they
the scheme, which prevent misutilization launched without a clear administrative are presently or previously affiliated.

issue focus
A Case Study for

Micro Health Insurance
VIMOSEWA’S CASHLESS HOSPITALIZATION
RAMESHWARI KHARVA DETAILS THE PURPOSEFULNESS OF CASHLESS HOSPITALIZATION AND OBSERVES THAT THE INITIAL
HARDSHIP ASSOCIATED WITH ITS IMPLEMENTATION HAS BEEN WORTH ITS WHILE.
Background Under health insurance, it has been its health insurance claimants in 2004. The
S
EWA, (Self Employed Women’s providing hospitalization insurance to its system was initiated in eight rural talukas
Association) is working to organize members. (blocks) which had a high number of
self-employed women to make them insurance members. Under this system,
fully employed and self-reliant. In the Earlier system of claim claimants could get reimbursed while they
SEWA union, more than 120 categories of reimbursement were still in hospital. Also, the VimoSEWA
workers have been organized and mainly Hitherto, under the health insurance local leader used to assist the member in
divided into categories like home based scheme if a member was hospitalized, she getting the documents. However, to avail
workers; street vendors; service providers could go to a provider of her choice. At this benefit, members had to seek
and manual laborers; and producers. the time of hospitalization, she had to pay
out of her own pocket for expenses
VimoSEWA is the insurance unit of SEWA (a
incurred. She then had to submit her
member based organization of Self-
hospitalization related documents to the
Employed Women Workers). SEWA’s
VimoSEWA. The claims committee at Vimo
insurance program started in the early
1990’s in response to our members’
SEWA examined these documents and The integrated
reimbursed the member for admissible
continuing quest for social protection and scheme incorporates
claims.
self-reliance. In 1992, SEWA’s Integrated health insurance as a
Social Security Scheme was initiated with
Piloting of Cashless system of crucial programme.
coverage for life, asset loss, widowhood,
personal accident, sickness and maternity
reimbursement The most important
One of the research initiatives of VimoSEWA
benefits. need and in other
highlighted some problems with this
system. The most important problem was
words the risk that
Health Insurance Programme
that when a member gets hospitalized, SEWA members are
The integrated scheme incorporates health
insurance as a crucial programme. The
initially she needs to have cash in hand facing is expenditure
and besides, collection and submission of
most important need and in other words incurred on sickness.
documents prevented some members from
the risk that SEWA members are facing is
taking advantage of our services.
expenditure incurred on sickness. So to
provide protection for such risks, heatlh To reduce these barriers, VimoSEWA piloted
insurance was included in its package. a system of prospective reimbursement for

issue focus
hospitalization in selected hospitals. The in the communities where our members

reason for offering this facility in selected reside to know more about their
hospitals was two-fold. For one, it would preferences for hospital care and the
be logistically impossible for VimoSEWA reasons for the same. A short listing of
We also conducted
aagewans to reach the various hospitals hospitals was then prepared which includes focus group
used by SEWA members. Secondly, the government, trust and private hospitals. discussions in the
hospitals were selected on the basis of VimoSEWA decided to select either
communities where
quality of services and charging reasonable government or trust hospitals; private
rates. If members could be steered to the hospitals were selected only in areas where
our members reside
selected hospitals, VimoSEWA could make no suitable government or trust hospitals to know more about
a more concerted effort to ensure quality were available. In these hospitals, special their preferences for
services at reasonable costs for its care was taken to negotiate the costs that
hospital care and the
members. VimoSEWA members would be charged for
treatment. Criteria for hospital selection
reasons for the same.
Introducing Cashless system in were as follows: A short listing of
Ahmedabad city • Popularity of the hospital among hospitals was then
Based on the positive experience of members prepared which
prospective reimbursement in rural areas
• Member density in and around the
of Gujarat, in January 2006, VimoSEWA includes government,
hospital location (5-7 kms)
introduced the system in Ahmedabad city
• Availability of doctors, specialists and
trust and private
– it was renamed ‘cashless (CL)
services at the hospitals hospitals.
hospitalization’. VimoSEWA members
• Availability of low cost quality care.
could choose to use this new system of
claim reimbursement or use the previous
Hospitals linked with Cashless
system. The objectives continued to be
Reimbursement in Ahmedabad
the same that VimoSEWA had in rural areas,
in 2007
viz. using the information on the pamphlet
Presently, the number of Trust,
• To facilitate access to hospitalization by given to her. If the sthanikben responsible
Government and Private Hospitals in
providing immediate cash for for the hospital is not available on the
Ahmedabad city is as follows:
hospitalization expenses phone, the member can call up any of the
Trust Government Private other eight listed sthanikbens.
• To reduce the burden of collecting the
required hospitalization documents for 15 4 3 (Note: In Ahmedabad city we have 6 such
submitting a claim sthanikbens handling 22 hospitals and in
In rural areas also, the ratio of trust
• To direct members to inpatient facilities rural block, there is one sthanikben per
hospitals is higher.
with acceptable levels of quality taluka.)
• To avoid unnecessary hospitalization and Trust Government Private
cases of moral hazards by the medical The sthanikben tells the member (over
9 3 3
practitioners phone) to keep ready a photocopy of the
• To reduce the claim ratio; and insurance receipt and the original bills for
Process of Cashless Claim the costs incurred by the member until
• To reduce administrative cost of claim
Reimbursement then.
servicing.
Step 1
Step 3
Hospital Selection criteria Insured goes to one of the selected
Sthanikben visits the patient/member at
The first step was to select hospitals to be hospitals.
the hospital after ensuring that the
included in the system. VimoSEWA’s health Step 2 member has spent at least 24 hours in the
claims database provided an initial list of A family member makes a phone call to hospital. She collects a copy of the vimo
hospitals used by VimoSEWA’s members. the ‘Sthanikben’ (local leader, specially receipt from the member and also
We also conducted focus group discussions assigned the task of cashless servicing) information on the diagnosis of the patient,

issue focus
expected duration of hospital stay and payment can be made at that time. The - Members would sometimes phone from
estimated cost of treatment. She enters member is thus paid in a minimum of two a public call booth. However, before
this information in a prescribed format. and maximum of three installments. If the they could give the complete
hospitalization period is prolonged, then information about the hospital name,
Step 4
the member is made an interim payment. ward number, bed no. etc., their
Sthanikben comes to Vimo office with the
As far as possible, all payments are made money would run out. It therefore
information and the claims team
at the hospital itself; however, sometimes became difficult for the Sthanikben to
scrutinizes the documents to decide if the
the sthanikben has to go to the member’s locate the members.
claim is payable (In rural blocks,
home to settle the payment. This occurs
sthanikben verifies the claim on phone • Members contacting their local aagewans
if the member does not inform the
only). If so, the sthanikben collects cash instead of the sthanikben:
sthanikben on being discharged or if
to be paid to the patient. If the claim is - The other problem we faced was that
certain bills are submitted post-
not payable, then the member is informed the members would phone up their
hospitalization. The member’s signature is
about the same along with the reasons for local aagewans i.e. the person from
taken on the cash voucher on receipt of
the claim getting rejected. If a decision whom they had purchased the
the payment.
on the claim cannot be taken immediately, insurance instead of phoning the
the member is informed about the same Step 6 sthanikben. The information either
and she is advised to submit the claim as a On making all the payments, the does not reach the sthanikben or
‘regular’ claim. sthanikben submits the cash voucher and reaches her too late to service the
corresponding documents to the claims claim in the hospital..
Step 5
team at Vimo SEWA.
If the claim is payable, the sthanikben • Delayed information to sthanikben:
makes a first installment cash payment to Step 7 - Many members would call the
the member. The member is instructed to The cashless case is considered closed Sthanikben at the time of discharge.
contact the sthanikben as soon as the when the member is reimbursed
Under such circumstances, the
discharge notice is given, so that the final completely (as per the eligible amount);
sthanikben cannot reimburse the
and all corresponding documents and
members in the hospital because she
original bills are submitted to the claims
did not have any time to verify and
team.
process the claim.
Initial challenges
In 2006, the first year of the cashless
Addressing the challenges
The solution for the above problems was
programme in Ahmedabad city, this method
The cashless case is to strengthen the education given to
of reimbursement was optional for
considered closed members. In 2007 it was made mandatory members. As a result of this, after eight
when the member is and members were required to go only to month of the cashless system, 60% of total
cashless claims are reimbursed through
reimbursed one of the selected hospitals and use the
CL reimbursement system. using the proper channel.
completely (as per
the eligible amount); During the first year of the system in
Experience of Cashless
Ahmedabad city, 24% of the total claimants
and all Hospitalization in Ahmedabad
used this facility. The same process is
corresponding City
practised now where members do not have
• Although the aim was to have 100%
documents and choice of hospitals, they have to go to the
cashless system in 2007, by the end of
original bills are selected hospitals by VimoSEWA.
August 2007, 51% of the total claimants
submitted to the During the first eight months of 2007, the have utilized this system. However,
claims team. challenges we faced are listed below. there has been a steady increase in the
• Sthanikbens unable to make contact with proportion of cashless claims as can be
hospitalized members: seen in the figure below.

issue focus
Month Cashless Normal % of • The average claim cost has

claims claims Cashless decreased from Rs.1841/- of
Jan 75 124 38% regular claims to Rs.1761/- of
Feb 104 122 46% cashless claims.
Mar 92 123 43% • The cashless system has

Apr 104 110 49% reduced the claim processing
May 135 121 53% period as it takes only the
Jun 158 127 55% number of days the member

is hospitalized while in the
Jul 195 149 57%
normal system, it takes more
Aug 172 106 62%
than that.
Total 1035 982 51%
• The rejection rate for
cashless hospitalization is 3% as against
average claim payout as much as we can,
Claim experience: Cashless Vs. 18% for normal claims. The response of
by organizing regular meetings and
Normal (Ahmedabad City) the hospitals cannot be ignored, as
workshops with the doctors of tie-up
Servicing cost per claim doctors are in direct contact of our
hospitals.
• At the same time, looking at the cost sthanikbens. In government hospital, it
effectiveness of this system, the cost of is very difficult to get the written
servicing cashless claims is Rs.278/- per diagnosis on the visit report of SEWA but
claim as against Rs.342/- of normal claim as our sthanikben visits the hospital on
cost. So, cashless not only provides the a regular basis, they have very good
immediate reimbursement to the rapport with the hospital staff and thus
members but also helps in reducing the they can easily get the written diagnosis.
cost for the organization. • The Trust and Private hospitals assist the
Month Cashless Normal SEWA members in terms of reducing the
hospital charges and also in providing The cashless system
Jan 502/- 360/-
Feb 353/- 372/-
proper documents. has reduced the
Mar 329/- 482/- claim processing
Hospital Preference
April 351/- 404/- period as it takes
The graph clearly shows that trust hospitals
May 262/- 291/-
(N=860) and government hospitals (N=660)
only the number of
June 228/- 295/- are preferred to private providers (N=82). days the member is
July 188/- 238/- Amongst all the hospitals, a government hospitalized while in
Aug 216/- 336/- hospital has the highest number of claims the normal system, it
(258). Thus cashless system has been
Total 278/- 342/- takes more than that.
successful in making its members
access low cost quality care at
reasonable rates.
Future Plans
In short, cashless hospitalization has
been the most successful programme
of VimoSEWA and it has achieved
almost all the mentioned objectives.
We are proceeding in the direction The author is Training Co-ordinator,
of minimizing the servicing and VimoSEWA.

follow through
Agriculture Insurance in India

ASSOCIATED PROBLEMS
S.S. KUKREJA AND GAURAV NAGAR WRITE THAT IN ORDER TO PROVIDE SUPPORT TO THE FARMING COMMUNITY IN A
TRUE SENSE, AGRICULTURE INSURANCE PRODUCTS NEED TO BE ACTUARIALLY BASED AND REALISTIC IN THEIR DESIGNING.
A
griculture, the backbone of India, their agricultural risks to a third party.
provides gainful employment to Apart from above cited risks, farmers are
more than two thirds of the also exposed to risks which pertain to their
Agricultural activities
population and contributes about 30% of income generating assets like tractor, are prone to various
GDP. It also earns valuable foreign cattle etc. Since the definition of risks like floods,
exchange and supplies raw materials to agriculture comprises many ancillary
various key industries apart from fulfilling activities like pisci-culture, seri-culture,
droughts, weather
food requirements of the country. The poultry etc; it is imperative that the vagaries, pests,
combination of high concentration of benefits of insurance reach the masses in diseases etc.
manpower in agriculture sector, mostly lean periods who are not just involved in
unorganized, with high density of poverty direct crop cultivation but also in allied Weather, which plays
is a cause calling for various risk mitigation activities. a great role in the
mechanisms. success of cultivation,
Agricultural Risks
Life in rural India inherits a lot of risks Risks in agriculture can be broadly is a risk which cannot
and farmers are at the mercy of vagaries classified into two types of risks:- be controlled or
of nature. The farming community is
exposed to both controllable risks (like
• Pre-cultivation & Growth Phase risks averted.
(Production risks): It involves weather
sickness, medical emergencies which can
vagaries, pests and diseases, improper
be mitigated by ploughing in own
cultivation practices, paucity of
resources) and uncontrollable risks like
resources etc.
droughts, cyclones etc. which deliver the control of human beings. It also
heavy punitive damages and require • Post cultivation risks (Market risks):
includes acts of God like heavy or no
insurance protection. Refers to losses due to adverse market
rainfall, droughts, cyclones etc.
dynamics, improper prices, glut,
speculation activities of traders etc. Crop insurance in India has been a widely
Need for Agriculture Insurance in
discussed concern in esoteric circles where
India
Agricultural activities are prone to various
Agriculture Insurance Programs in it lost direction due to being buried in maze
risks like floods, droughts, weather
India of paperwork or destined for failure due
Typically, risks which pertain to farming to ill conceived, non-scientifically drafted
vagaries, pests, diseases etc. Weather,
can be categorized into two broad schemes. Hardly any of the schemes had
which plays a great role in the success of
categories; a) Crop based b) Non Crop adequate risk spread with solid actuarial
cultivation, is a risk which cannot be
based. Our discussion in this paper will premium indexing.
controlled or averted. Farming,
address the former.
particularly in India, is heavily dependent The schemes have correctly focused on
on monsoon. In such a scenario it is Crop based risks basically involves those homogeneous area approach instead of
necessary to have a mechanism like crop factors which have a bearing on the crop individual farmer approach due to lack of
insurance which enables them to transfer due to adverse conditions and are beyond dependable historical yield data for a

follow through
particular farmland to arrive at sound Farmers covered : 76,265,438 Total Area covered : 121,686,846
actuarial premium rates. The Central hectares
Total Area covered : 1, 27,570,282
Government’s pilot schemes did not find Total Sum insured : Rs .7, 075,773 lakhs
hectares
many takers amongst the states due to high
Total Sum insured : Rs .24949 Crores Total premium : Rs 2, 22,774 lakhs
financial implications since the
Total Insurance Total Claims paid : Rs. 6, 82,938 lakhs
governments had to act as reinsurers. In
charges : Rs 403.56 Crores (Source- AIC)
this backdrop of repeated ineffectiveness
of the schemes, the Agricultural Price Total Claims : Rs. 2303.45 Crores
Reasons for failures of
Commission, in 1970, revaluated the Claim Ratio : 1:5.71 Government aided Programs
economic, administrative, financial and
(Source - AIC) Financially these programs had yielded
actuarial dimensions of the crop insurances
enormous losses to government. One of the
in India. It found the schemes as waste of In 1999, CCIS was replaced by National
prominent features of all the above
scarce financial resources and advised for Agricultural insurance scheme (NAIS) or
programs is that they had been highly
abandoning the enterprise. Those were Rashtriya Krishi Bima Yojna (RKBY). NAIS
subsidized. Government not just paid
days of collectivist economic policies and was considered to be an improved version
premiums but also bore administrative
socialist planners kept harping back, in of CCIS, but there were certain limitations
costs and thus their total costs exceeded
political tones, on the necessities of such to it. NAIS was implemented by GIC. The
their incomes, thus creating an invisible
measures. As a result, schemes kept on main feature of the scheme was to protect
barrier for private players to try their hands
popping on ad-hoc basis until 1985 when farmers against losses suffered by them
in agriculture insurance.
CCIS (Comprehensive Crop Insurance due to crop failure on account of natural
Scheme) was ushered in on the basis of calamities such as drought, flood,
Major reasons why crop insurance
learning from PCIS (Pilot Crop Insurance hailstorm, cyclone etc. It was presumed
failed are as follows
Scheme). Based on homogeneous area that NAIS will weed out the limitations of
CCIS in the long run on the basis of sound • Lack of sound administrative practices
approach, it was a multi institutional
groundwork, learning lessons from past by insurers,
agencies participation scheme involving
experiences and with the help of rates • Insurance of uninsurable risks,
Govt. of India & State Govt Agriculture
derived from sound historical data and • Involvement of insurers with farmers for
Departments, Banking Institutions & GIC.
sound actuarial rates. falsified claims due to lack of control,
CCIS was implemented from season of
• Use of insurers for political reasons,
Kharif 1985 to Kharif 1999, which was later Since inceptions till the year 2005, AIC data • No portfolio/risk management,
replaced by National Agriculture Insurance reports progress of NAIS as follows: • Lack of actuarial rates,
scheme (NAIS).
Farmers covered : Rs. 75112215 lakhs • CCIS considered as bancassurance,
CCIS was an optional scheme for states.
Fifteen states and two UTs adopted the
scheme to be implemented in their CCIS Vs NAIS
respective states. (Source AIC). Parameters CCIS NAIS
Farmers Loanee Farmers Compulsory for loanee farmers / optional
covered for non loanee farmers
Main features of CCIS were: Crop Covered Food crops & oilseeds All CCIS crops + Annual commercial /
• Premium rates were 2% for Cereals and horticulture crops
Premium 50% subsidy for small and marginal 50% in first year for small and marginal
millets; and 1% for pulses and oil seeds.
subsidy farmers farmers but to be phased out in five
50% of the premiums payable were years.
subsidized and shared equally by state Limit of Rs.10000 per farmer Up to the value of 150% of average yield.
and central government; sum insured However sum insured exceeding value of
threshold yield shall attract premium at
• Premium and claims were shared in actuarial rate
2:1 ratio; Participation Compulsory for loanee farmers Compulsory for loanee farmers and
• Max. Sum Insured was 100% of crop loan by farmers optional for non loanees
Approach Area approach Area approach. However in case of
which was later increased to 150%; localized calamities, individual
• Mandatory for farmers availing short assessment in limited areas
term crop loans. Admin exp GOI to reimburse 50% of expenses GOI to reimburse 100% which is to be
reduced on sunset basis. From 6th year
Since inceptions till the end of CCIS in 1999 onwards, all expenses to be borne by
the following nos. were achieved: implementing agencies

follow through
the farmers of specified crop against conventional weather products. Rainfall

deviation in rainfall. Since it was a pilot insurance products are best example of
approach, the numbers were limited. such products. Farmers get benefited if
One of the problems Following the path, during Kharif 2004, rainfall goes beyond a threshold level with
in index based IFFCO-Tokio General Insurance, another stipulated compensation amount. This will
weather insurance is private general insurance company, eventually help in reduction of moral
launched its own variant of index based hazard, adverse selection and transaction
that an individual rainfall insurance program during kharif costs. One of the problems in index based
can suffer a loss but season, initially in four states and as on weather insurance is that an individual can
still may not get a date in ten states. Having learnt valuable suffer a loss but still may not get a claim
lessons from such enterprises, pilots are because the risk trigger did not occur. A
claim because the now being done on protection from farmer availing rainfall insurance can lose
risk trigger did not weather vagaries occurring during Rabi his crop but may not get compensated
occur. crops. since the reference data station figures
remain above trigger point. Agriculture
Private weather insurance products have
insurance products, which are to be
been gaining momentum in agricultural
offered, must be able to suit the farmers’
• Lack of agricultural knowledge for market. Some of the prominent features
needs. It is highly desirable that
insurer, of these products are:
Government should utilize its money in
• Subsidy a major barrier for private
• Point of sale policy issuance - receipt setting up of agriculture infrastructure and
players,
cum policy, research which will eventually have long
• Underestimation of risk assessment and
• Policy and promotion in vernacular term effects instead of financing the
occurrence.
language, premiums. Premiums should be based on
• Revision of policy every year based on sound actuarial data with rational risk
Role of Private sector in past data /experiences, management techniques. Research costs
Agriculture Insurance • Local IMD weather station to be of crop insurance programs, education of
With the opening up of insurance sector in
considered as reference stations. farmers about value of rainfall insurance,
2000, the scenario of insurance industry
Issues with private weather insurance ensuring secured rainfall stations, legal and
has taken a dramatic turn. There exists a
schemes which curtail expansion in wider regulatory frameworks etc are some of the
vast potential in rural and semi urban,
geographical areas are as: issues which require considerable
particularly in agriculture where benefit
deliberation form the government’s side.
of insurance is highly solicited but not • Service and claims issues,
reached. It is to be mentioned that despite • Price not affordable, During Rabi 2007, a weather-based
regulatory requirements, companies are • Farmers perceiving insurance as agricultural insurance scheme, where
not taking much initiatives to spread their investment with sure returns instead of premiums are evenly subsidized by the
reach in rural sector. Most of their risk mitigation tool, Union Government and States has been
initiatives are just to fulfill the regulatory • Absence of relevant weather data, rolled out across select districts in 12 states
requirements of IRDA. One of the • Absence of government infrastructure in as part of a new initiative by the
prominent features of rural sector is that setting up weather stations to be used Government to offset risks underlying
of strong saving habits, and hence as reference weather stations, Indian farming. This is the first occasion
providing a huge potential to various • Misappropriate data correlation with risk that the government is using private
industries including insurance. But lack of occurrence, insurers for a subsidized agricultural
cost effective service delivery model and • Small Holding size and wide variety of insurance package.
perception of huge investments in the agricultural practices,
sector deters them to exploit the • Moral hazards.
opportunities. Mr. S.S Kukreja is Vice President & Head-
Role of private sector in agriculture Road ahead Rural , Masses & Cooperatives, IFFCO Tokio
General Insurance Company Private Ltd; and
insurance had been limited to certain index From the era of multi crop insurance, we
Mr. Gaurav Nagar is Assistant Manager-Rural ,
based weather schemes. It started in year have come to Index based weather Masses & Cooperatives, IFFCO Tokio General
2003 when ICICI Lombard, a private general insurance schemes. It is visualized that Insurance Company Private Ltd. The views
and opinions expressed in the article are
insurance company, started its pilot Index based weather contracts will
those of the authors and not of any
program on rainfall insurance to protect eliminate the drawbacks associated with organization or institution.

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statistics - non-life insurance
Report Card: General

GROSS PREMIUM UNDERWRITTEN FOR AND UP TO THE MONTH OF NOVEMBER 2007
(Rs.in Crores)
NOVEMBER APRIL - NOVEMBER GROWTH OVER THE
INSURER CORRESPONDING PERIOD
2007-08 2006-07 2007-08 2006-07
OF PREVIOUS YEAR
Royal Sundaram 60.45 47.67 439.76 388.84 13.09
Tata-AIG 55.28 62.45 527.69 520.12 1.46
Reliance General 186.68 75.19 1315.36 520.85 152.54
IFFCO-Tokio 97.49 84.18 708.35 813.15 -12.89
ICICI-lombard 283.98 243.33 2348.10 2078.69 12.96
Bajaj Allianz 190.45 153.32 1515.52 1158.87 30.78
HDFC General 18.63 16.31 148.18 125.88 17.71
Cholamandalam 34.23 23.73 349.02 206.68 68.87
Future Generali* 0.86 0.86
New India 403.32 356.98 3520.36 3316.14 6.16
National 316.00 291.34 2591.89 2428.54 6.73
United India 303.64 313.88 2443.45 2351.60 3.91
Oriental 276.11 305.36 2600.49 2650.47 -1.89
PRIVATE TOTAL 928.04 706.18 7352.84 5813.07 26.49
PUBLIC TOTAL 1299.07 1267.56 11156.19 10746.75 3.81
GRAND TOTAL 2227.12 1973.74 18509.02 16559.81 11.77
SPECIALISED INSTITUTIONS
Credit Insurance
ECGC 55.38 51.79 420.26 391.67 7.30
Health Insurance
Star Health & Allied Insurance 3.55 0.78 98.45 14.61 573.75
Apollo DKV* 0.02 0.02
Health Total 3.57 0.78 98.47 14.61 573.87
Note: Compiled on the basis of data submitted by the Insurance companies

* Commenced operations in November, 2007.

round up
‘Micro-insurance Conference 2007’ was jointly hosted

by CGAP Working Group on Micro-insurance and
Munich Re Foundation, and supported by IRDA; at
Mumbai between 13th and 15th November, 2007.
Mr. P. Chidambaram, Hon’ble Minister of

Finance, Government of India lighting the
lamp at the inaugural session. Also seen in
the picture are (from L to R): Mr. Thomas
Loster – Chairman, Munich Re Foundation,
Germany; Mr. C.S. Rao – Chairman, IRDA,
India; and Mr. Michel Flamee, Chair of
Executive Committee of the IAIS,
Switzerland.
Mr. C.S. Rao delivering the

Welcome Address.

round up
Outlook Money and NDTV Profit organized a summit

at Mumbai on 26th October, 2007.
Mr. G. Prabhakara, Member (Life), IRDA

speaking on ‘Safeguarding Customer Interest
through Better Intermediation’.
(from L to R): Mr. Kshitij Jain, CEO,

ING-Vysya Life Insurance Co.; Ms. Monica
Halan, Editor, Outlook Money;
Mr. G. Prabahakara; Ms. Shikha Sharma, MD
& CEO, ICICI Prudential Life Insurance Co.;
Mr. Nandagopal, CEO, Reliance Life
Insurance Co.; and Mr. Trevor Bull, CEO,
Tata AIG Life Insurance Co.

events
10 Jan 2008 Indian Insurance Industry – Road Ahead

Venue: Kolkata By Indian Chamber of Commerce
14 - 15 Jan 2008 Insurance & Takaful Fraud Conference

Venue: Kuala Lumpur, Malaysia By Insurance Services Malaysia Berhad
17 - 18 Jan 2008 3rd Seminar on Health Insurance and Care

Venue: NIA, Pune By Institute of Actuaries of India, Mumbai
21 - 23 Jan 2008 1st India Rendezvous 2008

Venue: New Delhi By Asia Insurance Review, Singapore
28 - 29 Jan 2008 ASHK Regional Conference

Venue: Macau By Actuarial Society of Hong Kong
30 Jan - 1 Feb 2008 8th CEO Insurance Summit in Asia

Venue: Jakarta, Indonesia By Asia Insurance Review, Singapore
7 – 8 Feb 2008 10th Global Conference of Actuaries

Venue: Mumbai By International Actuarial Association &
Institute of Actuaries of India
11 – 16 Feb 2008 Management of Marine Insurance (Cargo & Hull)

Venue: Pune By NIA Pune
12 - 13 Feb 2008 Takaful Conference on Islamic Investment Management

Venue: Dubai, UAE By Asia Insurance Review, Singapore
26 - 28 Feb 2008 GAIF Conference

Venue: Bahrain By General Arab Insurance Federation
3 - 4 Mar 2008 Asian Conference on M&As, Commutations & Run Offs

Venue: Singapore By Asia Insurance Review, Singapore

RNI No: APBIL/2002/9589
“ view point
Identity theft is one of the fastest growing crimes in the United States, affecting
consumers of all ages. It’s critical for consumers to know how to protect themselves
and reduce the risk of becoming a victim.
Ms Sandy Praeger
NAIC President and Kansas Insurance Commissioner
In the last two years, insurance companies have made huge gains from their
investment portfolios thanks to (China’s) booming market. So much so that their
portfolios have become the main source of their profits... making it quite difficult
for them to make profits from the underwriting business.
Mr Li Kemu
Vice-Chairman of the China Insurance Regulatory Commission
For the continued development of the health insurance market (in India), and also
to protect the long-term interests of the insured persons; there is a responsibility
on all stakeholders in the system for ensuring sustainability of health insurance.
Mr CS Rao
Chairman, Insurance Regulatory & Development Authority, India
Reinsurance is effectively a substitute for capital and it is in the interests of all

policyholders and claimants that the funds to support insurers’ claims liabilities,
including amounts recoverable from reinsurers, be properly secured in Australia.
Mr John Trowbridge
Member, Australian Prudential Regulation Authority
Today, funds from insurance companies, pension funds and even retail investors are
made available for financing the infrastructure development needed for any country’s
continued economic growth.
Mr Kola Luu
Executive Director, Monetary Authority of Singapore
Rising affluence and aging population will open up new opportunities in retirement
planning and health maintenance; globalization and convergence of commercial
activities will make room for enterprise risk management; and emerging risks from
climate change and pandemics will generate demand for innovative and sophisticated
policy coverage.
Mr Clement Cheung
Commissioner of Insurance, Hong Kong

”

Irda Vol 6 Iss 2 (Jan 08) Final

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Volume VI, No.

’Ë◊Ê ÁﬂÁŸÿÊ◊∑§ •ı⁄U Áﬂ∑§Ê‚ ¬˝ÊÁœ∑§⁄UáÊ

© 2007 Insurance Regulatory and Development Authority.

IRDA Vol 6 Iss 2 (Jan 08) FINAL.pmd 2 1/7/2008, 4:54 PM

The real test of success for any class of insurance

IRDA Vol 6 Iss 2 (Jan 08) FINAL.pmd 3 1/7/2008, 4:54 PM

mççcçáoççÆ³çkçÀ nÌuLç yççÇcçç - kçÀªCçç ì^mì kçÀç DçvçáYçJç

Statistics - Non-Life Insurance 46

Health Insurance in India

Sustainable Private Health Insurance

Designing New Health Insurance Products

Health Security for All

A Case Study for Micro Health Insurance

IRDA Vol 6 Iss 2 (Jan 08) FINAL.pmd 4 1/7/2008, 4:54 PM

IRDA Vol 6 Iss 2 (Jan 08) FINAL.pmd 5 1/7/2008, 4:54 PM

statistics - life insurance

Nov, 07 Up to Nov, 07 Up to Nov, 06 Nov, 07 Up to Nov, 07 Up to Nov, 06 Nov, 07 Up to Nov, 07 Up to Nov, 06

Group Single Premium 0.00 0.81 2.31 0 0 0 0 183 517

Individual Non-Single Premium 210.15 970.33 466.55 58985 306301 211075

Individual Non-Single Premium 68.62 415.17 325.12 40190 273968 251606

statistics - life insurance

Individual Non-Single Premium 57.80 315.25 123.42 17803 113765 52595

Individual Single Premium 18.32 92.55 35.34 3172 17058 7551

Group Single Premium 0.00 0.00 0.00 0 0 0 0 0 0

Insurance – Essential Part of One’s Portfolio

Securing Personal Assets

in the next issue...

irda journal 6 Jan 2008

IRDA Vol 6 Iss 2 (Jan 08) FINAL.pmd 8 1/7/2008, 4:54 PM

To Insurers may file a fresh schedule of rates and rating guidelines

irda journal 7 Jan 2008

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To b) Information specific to the particular policy holder only

irda journal 8 Jan 2008

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At the start of 1 2 3 4 5 6 7 8 9 10 and

Amount allotted for investment

IN THIS POLICY, THE INVESTMENT RISK IS BORNE BY THE POLICY HOLDER

Marketing officials’ Policyholders’ Signature

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Health Insurance in India

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A s income levels and health awareness

irda journal 12 Jan 2008

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majority of the opportunity lies in Product innovation

irda journal 13 Jan 2008

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these patients is achievable and If a terminal illness is involved, then

irda journal 19 Jan 2008