A PROJECT ON

“HEALTH INSURANCE PLANS”

SUBMITTED BY:
MR. AKASH PRAKASH BHANDARY
Roll No. 330
Submitted to,

UNIVERSITY OF MUMBAI
BACHELOR OF COMMERCE
(BANKING AND INSURANCE) Semester VI

(2019-2020)
Project Guidance by
Professor: DEVENDRA VYAS

Uttari Bharat Sabha’s

RAMANAND ARYA D.A.V. COLLEGE
DATAR COLONY BHANDUP (E), MUMBAI- 400042.
 A PROJECT ON
“HEALTH INSURANCE PLANS”

BACHELOR OF COMMERCE
(BANKING AND INSURANCE) Semester VI

(2019-2020)
MR. AKASH PRAKASH BHANDARY
Roll No. 330
Submitted to,

UNIVERSITY OF MUMBAI
Project Guidance by
Professor: DEVENDRA VYAS

Uttari Bharat Sabha’s

RAMANAND ARYA D.A.V. COLLEGE DATAR COLONY BHANDUP
(E), MUMBAI- 400042.
 A PROJECT ON
“HEALTH INSURANCE PLANS”

BACHELOR OF COMMERCE
(BANKING AND INSURANCE)
Semester VI

University of Mumbai
(2019-2020)
Submitted to:
In Partial Fulfilment of the requirements
For the Award of Degree of Bachelor of Commerce
(Banking and Insurance) By
MR. AKASH PRAKASH BHANDARY
Roll No. 330

Uttari Bharat Sabha’s

RAMANAND ARYA D.A.V. COLLEGE
DATAR COLONY BHANDUP (E), MUMBAI-400042.
 DECLARATION

I, MR. AKASH PRAKASH BHANDARY the Student of Bachelor of Commerce

(Banking and Insurance) Semester VI (2018-2019) hereby declare that have completed the
Project on “HEALTH INSURANCE PLANS” The information submitted is true and original to the best of
my knowledge.

SIGNATURE OF THE STUDENT

MR. AKASH PRAKASH BHANDARY
ROLL NO.330
 Uttari Bharat Sabha’s
RAMANAND ARYA D.A.V. COLLEGE DATAR COLONY
BHANDUP (E) MUMBAI-400042.

CERTIFICATE
This is to certify that MR. AKASH PRAKASH BHANDARY, Roll No.330 of Bachelor of Commerce
(Banking and Insurance) Semester VI (2019-20) has successfully completed the project on “HEALTH
INSURANCE PLANS” under the guidance of DEVENDRA VYAS

Date -____________

Course Co-coordinator Principal

Ms. Chandrakala Srivastava Dr. Ajay Bhamare

Project Guide / Internal Examiner External Examiner Prof.

Devendra vyas
 ACKNOWLEDEMENT
I owe a great many thanks to a great many people who helped and supported me doing the writing of this
book.

My deepest thanks to lecturer, Prof. DEVENDRA VYAS Guide of the project for guiding &correcting
various documents of mine with attention care. He has taken pains to through my project and make necessary
corrections as and when needed.

I extended my thanks to the principal Dr. Ajay Bhamare of Ramanand Arya D.A.V. College of Commerce
&Science for extending support. My deep sense of gratitude to Principal Dr. Ajay Bhamare of Ramanand
Arya D.A.V College of Commerce & Science for support & guidance. Thanks and appreciation to the helpful
people at Ramanand Arya D.A.V College of Commerce & Science, for the support.

I would also thank my institution and faculty without whom this project has been a distant reality. I also
extended my heartfelt thanks to my family and well-wishers.
 INDEX

SR.NO PARTICULARS PAGE

NO
INDUSTRY PROFILE 9
CHAPTER 1 INTRODUCTION

1.1 MEANING
1.2 DEFINITION
1.3 HOW HEALTH INSURANCE WORKS
1.4 ORIGIN OF HEALTH INSURANCE

1.5 TYPE OF HEALTH INSURANCE

1.6 KEY BENEFITS OF HEALTH INSURANCE PLANS
1.7 IRDA
CHAPTER 2 RESEARCH METHODOLOGY 10-14
2.1 OBJECTIVE
2.2 NEED FOR STUDY
2.3 HOW TO SELECT INSURANCE PLANS
2.4 WHAT IS THE ELIGIBILITY CRITERIA OF HEALTH INSURANCE
2.5 DOCUMENTS REQUIRED WHEN BUYING HEALTH INSURANCE
PLANS
2.6 TAX BENEFITS OF HEALTH INSURANCE PLANS
2.7 HEALTH INSURANCE CLAIM PROCESS
2.8 SOME OF HEALTH INSURANCE POLICIES IN INDIA
2.9 HEALTH CARE SCHEMES BY GOVERNMENT OF INDIA
2.10 CHALLENGES FACED BY HEALTH INSURACE COMPANIES
2.11 FACTORS THAT AFFECT YOUR HEALTH INSURANCE
PREMIUM
2.12 FACTORS THAT DON’T AFFECT YOUR HEALTH INSDURANCE
PREMIUMS
2.13 OTHER THINGS TO CONSIDER WHEN CHOOSING A HEALTH
INSURANCE PLANS

CHAPTER 3 LITERATURE REVIEW 26-30

CHAPTER 4 DATA ANALYSIS, INTERPRETATION AND PRESENTATION 31-84
CHAPTER 5 CONCLUSION 85-86
5.1 CONCLUSION
 5.2 SUGGESTIONS
CHAPTER 6 QUESTIONAIRE 87-92
CHAPTER 7 BIBLIOGRAPHY/WEBLIOGRAPHY 93
 INDUSTRY PROFILE

INSURANCE:
Insurance is a means of protection from financial loss. It is a form of risk management, primarily used to
hedge against the risk of a contingent or uncertain loss.
An entity which provides insurance is known as an insurer, insurance company, insurance carrier or
underwriter. A person or entity who buys insurance is known as an insured or as a policyholder. The
insurance transaction involves the insured assuming a guaranteed and known relatively small loss in the
form of payment to the insurer in exchange for the insurer's promise to compensate the insured in the
event of a covered loss. The loss may or may not be financial, but it must be reducible to financial
terms, and usually involves something in which the insured has an insurable interest established by
ownership, possession, or pre-existing relationship.
The insured receives a contract, called the insurance policy, which details the conditions and
circumstances under which the insurer will compensate the insured. The amount of money charged by
the insurer to the policyholder for the coverage set forth in the insurance policy is called the premium. If
the insured experiences a loss which is potentially covered by the insurance policy, the insured submits
a claim to the insurer for processing by a claims adjuster. The insurer may hedge its own risk by taking
out reinsurance, whereby another insurance company agrees to carry some of the risk, especially if the
primary insurer deems the risk too large for it to carry.

TYPES OF INSURANCE:
 CHAPTER 1

INTRODUCTION OF HEALTH INSURANCE

1.1 Meaning

Health insurance (sometimes called health coverage) pays for some or all of the cost of the health services you
receive, like doctors’ visits, hospital stays and visits to the emergency room it helps keeps your health care
costs predictable and affordable. you may have to pay several different amounts for health insurance:

1.You will generally pay a premium, a monthly fixed payment to the insurance company

2.You may have to pay a deductible. This is a fixed amount that you pay out of pocket before your health
insurance begins to pay for your health services.

3. After you have met the deductible, you and your insurance company typically share the cost of covered
health services. Your insurance pays most of the cost first, and then you pay the remaining cost. The amount
you pay is either a copayment (a fixed amount) or a coinsurance (a percentage of the cost of the service).
 1.2 DEFINITION:

A contract between an insurance provider (e.g. an insurance company or a government) and an individual or
his/her sponsor (e.g. an employer or a community organization). The contract can be renewable (e.g.
annually, monthly) or lifelong in the case of private insurance, or be mandatory for all citizens in the case of
national plans. The type and amount of health care costs that will be covered by the health insurance
provider are specified in writing, in a member contract or "Evidence of Coverage" booklet for private
insurance, or in a national health policy for public insurance.

Health insurance is a type of insurance coverage that pays for medical, surgical, and sometimes dental
expenses incurred by the insured. Health insurance can reimburse the insured for expenses incurred from
illness or injury, or pay the care provider directly. It is often included in employer benefit packages as a
means of enticing quality employees, with premiums partially covered by the employer but often also
deducted from employee paychecks. The cost of health insurance premium is deductible to the payer, and
the benefits received are tax-free.

1.3 How health insurance works ?

Health insurance can be tricky to navigate. Managed care insurance plans require policyholders to receive
care from a network of designated healthcare providers for the highest level of coverage. If patients seek
care outside the network, they must pay a higher percentage of the cost. In some cases, the insurance
company may even refuse payment outright for services obtained out of network.

Many managed care plans—for example, health maintenance organisations and point of service plans —
require patients to choose a primary care physician who oversees the patient's care, makes recommendations
about treatment, and provides referrals for medical specialists. preferred provide organisation, by contrast,
don't require referrals, but do have lower rates for using in-network practitioners and services.

Insurance companies may also deny coverage for certain services that were obtained without
preauthorization. In addition, insurers may refuse payment for name-brand drugs if a generic version or
comparable medication is available at a lower cost. All these rules should be stated in the material provided
by the insurance company and should be carefully reviewed. It's worth checking with employers or the
company directly before incurring a major expense.
Increasingly, health insurance plans also have co-pays, which are set fees that plan subscribers must pay for
services such as doctor visits and prescription drugs; deductibles that must be met before health insurance
will cover or pay for a claim; and coinsurance , a percentage of healthcare costs that the insured must pay
even after they've met their deductible (and before they reach their out-of-pocket maximum for a given
period).

Insurance plans with higher out-of-pocket costs generally have smaller monthly premiums than plans with
low deductibles. When shopping for plans, individuals must weigh the benefits of lower monthly costs
against the potential risk of large out-of-pocket expenses in the case of a major illness or accident.

One increasingly popular type of health insurance is a highly deductible plan, which, in 2020, must have
IRS-mandated deductibles of at least $1,400 for an individual or $2,800 for a family, and out-of-pocket
maximums of $6,900 for an individual/$13,800 for a family.

These plans have lower premiums than an equivalent health insurance plan with a lower deductible. One
other advantage: If you have one, you are permitted to open—and contribute pre-tax income to—a health
saving account, which can be used to pay for qualified medical expenses. In addition to health insurance, ill
people who qualify can get help from a number of auxiliary products available on the market. These include
disability insurance, critical catastrophic illness and long-term care insurance.

1.4 ORIGIN OF HEALTH INSURANCE

Launched in 1986, the health insurance industry has grown significantly mainly due to liberalization of
economy and general awareness. According to the World Bank, by 2010, more than 25% of India's
population had access to some form of health insurance.

There are standalone health insurers along with government sponsored health insurance providers. Until
recently, to improve the awareness and reduce the procrastination for buying health insurance, the General
Insurance Corporation of India and the Insurance Regulatory and Development Authority (IRDA) had
launched an awareness campaign for all segments of the population.

Launched in 2007, the National Health Insurance Program (Rashtriya Shastria Yojana- RSBY) is led by the
Ministry of Health and was adopted by 29 states in 2014. It is funded 75% by the government and 25% by
the states. The worker and 4 of his dependents benefit from health insurance if they are not covered by any
system and live below the poverty line. RSBY beneficiaries are required to pay an annual registration fee of
INR 30 for hospital coverage up to INR 30,000 per year per family.
September 25th, 2018, the Indian government announced the launch of a new health insurance for the
poorest citizens. Indian Prime Minister, Narendra Modi announced that the new system is expected to reach
more than 500 million people and is called "Modicare". The reform is still in progress and aims to install
universal social security in the country.

1.5 Type of Health Insurance Plan

 Individual Health Insurance plan

 Family floater Health insurance plan
 Group Health cover
 Senior citizen health Insurance
 Critical Illness Health Cover
 Super Top-Up Policy

1.6 Key Benefits of Health Insurance Plans

There are several benefits offered by health insurance plans, including the following:

Coverage for pre and post hospitalization expenses-

Insurance policies usually offer coverage for expenses both before and after hospitalization up to pre-
specified durations/limits.

Cashless facility-

If you are getting treated at a network hospital, you can get hassle-free cashless treatment under your
insurance plan.

Ambulance and transportation costs-

Ambulance charges and other transportation costs of the person insured are also covered under health
insurance policies.

No-Claim Bonuses-

These bonuses are earned by the person insured in case no claims are filed for treatments in a particular year.

Room rent coverage-

Room expenses are also covered by insurance policies and this is dependent on the premium paid by the
customer.
Medical check-ups-

Insurance policies also offer coverage for periodic health check-ups. Some companies even offer free check-
ups on the basis of earlier no-claim bonuses.

Tax benefits-

You can get deduction up to `25,000 from taxable income of health insurance premiums paid under Section
80D of the Income Tax Act. The maximum deduction limit for senior citizens is `50,000.

1.7 INSURANCE REGULATORY DEPARTMENT AUTHORITY OF INDIA

(IRDAI)

The Insurance Regulatory and Development Authority of India (IRDAI) is an autonomous, statutory body
tasked with regulating and promoting the insurance and re-insurance industries in India. It was constituted
by the Insurance Regulatory and Development Authority Act, 1999, an Act of Parliament passed by the
Government of India. The agency's headquarters are in Hyderabad, Telangana, where it moved from Delhi in
2001.

IRDAI is a 10-member body including the chairman, five full-time and four part-time members appointed by
the government of India.
 CHAPTER-2

RESEARCH METHODOLOGY

2.1 OBJECTIVE OF THE STUDY:

 To assess the individual awareness about Health Insurance.

 To know the preference of individual regarding health insurance.
 To evaluate consumption patterns of health insurance.
 To assess the effectiveness of company services
 To analyze health insurance plan in India
 To analyze the present trend of health insurance
 To study the challenges faced by health insurance companies
 To study how health can be claimed
 To study the marketability
 To study the profitability
 To study the problems faced by insuree while claiming
2.2 NEED FOR STUDY

Buying a health insurance policy for yourself and your family is important because medical care is
expensive, especially in the private sector. Hospitalisation can burn a hole in your pocket and derail your
finances. It will become even tough, if the person who brings in the money, is now in a hospital bed. All this
can be avoided by just paying a small annual premium which would lessen your stress in case of medical
emergencies.

A good health insurance policy would usually cover expenses made towards doctor consultation fees, costs
towards medical tests, ambulance charges, hospitalization costs and even post-hospitalization recovery costs
to a certain extent.

2.3 HOW TO SELECT HEALTH INSURANCE PLANS?

It’s difficult to select the best insurance policies as all insurance company provides a similar type of
insurance plan. Hence some of the important points that any Person should look before purchasing any plans
are:

1. Sum Assured

2. Minimum Entry Age and renewability clause

3. Room Rent Capping

4. Inclusion and Exclusion

5. No Claim Bonus

6. Other Benefits
2.4 WHAT IS ELIGIBILITY CRITERIA OF HEALTH INSURANCE ?

In India, people under 45 years of age are not required to undergo a mandatory health check-up when
obtaining a health insurance policy. They are, however, required to disclose any pre-existing conditions such
as diabetes or hypertension. It is, therefore usually advised that one should get a health insurance when
young so that the premium would be less. The amount you pay towards health insurance premium claimed
as a tax-saving deduction under Section 80D. You can claim ₹25,000 annually for a health insurance policy
for yourself.

2.5 DOCUMENTS REQUIRED WHEN BUYING HEALTH INSURANCE PLANS:

There are few documents that you need to provide such as:

1. Age proof – Any one of Birth Certificate, 10th or 12th mark sheet, Driving License, Passport, Voter ID,
etc.

2.Identity proof – Driving License, Passport, Voter ID, PAN Card, Aadhar Card, which proves one’s
citizenship.

3. Address proof – Electricity Bill, Telephone Bill, Ration Card, Driving License, Passport, should clearly
mention the permanent address.

4.Some plans require a medical check-up (usually for elder people above the age of 45 years)

5. Passport Size Photo

2.6 TAX BENEFITS OF HEALTH INSURANCE PLAN

you also pay the premium for a health insurance policy for your parents, you can claim up to ₹30,000 for the
same as well.

Earning money is not at all useful if you don’t have a life. Think about yourself and your family and the
importance of life. You know the importance and benefits of having a Health Insurance Policy. Start one, if
you haven’t already.
2.7 HEALTH INSURANCE CLAIM PROCESS

A health Insurance policy equips you to get the best healthcare treatment without worrying about the huge
costs payable at the time of discharge. Therefore knowing about the claim process is an essential piece of
information that the insured individual should be aware of at all times.

The two main types of health insurance claim which an individual can choose from when making a claim
are:

 Cashless Claim Process

When the insured individual provides their health insurance details to the respective hospital, he/she begins
to receive treatment. Upon discharge, the hospital will forward the medical bills to the designated health
insurance company. The company will then audit the expenses and settle the outstanding payment due to the
hospital. This process is hassle-free for the insured as the payments are between the hospital and insurance
company.

 Reimbursement Claim Process

In the reimbursement claim process, the insured individual who has been admitted to a certain hospital pays
for the entire treatment until discharge. Once the insurer has paid for the treatment and hospitalization costs
incurred, he/she have to make a reimbursement claim to the particular insurance company. The insured
individual will have to provide original bills of the hospital to the health insurance and claim reimbursement.
The insurance company will audit the claim and will then decide to approve or reject it. On approval of the
insurance company, the claim will be made to the policyholder. The insurance company will notify the
insured individual in case the claim has been rejected.
2.8 Some of the Health Insurance Policies in India

1. Max Bupa Health Insurance

2. HDFC Ergo Health Insurance

3. Bharti Axa Health Insurance

4. SBI Health Insurance

5. L&T Health Insurance

6. Bajaj Allianz Health Insurance

7. Apollo Munich Health Insurance

8. National Health Insurance

2.9 Healthcare Schemes by Government of India

The Indian government (center & state) have launched numerous medical insurance schemes to improve
healthcare and make it accessible for the weaker sections of society Here is a list of health insurance
schemes provided by the government:

Rashtriya Swasthya Bima Yojana (RSBY): This scheme was launched by the Ministry of Labour and
Employment to provide health insurance coverage for families below the poverty line. The Beneficiaries
under this scheme can avail a health benefits cover of up to Rs.30,000. A registration fee of Rs 30 is
chargeable.

Pradhan Mantri Suraksha Bima Yojana: Is an initiative by the government to bring access to insurance
especially for the economically weaker sections of society. This scheme features affordable premiums and
provides compensation to the family of the deceased.

Central Government Health Scheme (CGHS): This scheme was launched in 1954. It provides
comprehensive healthcare facilities to the central government employees, pensioners and dependents of
these employees.

Aam Aadmi Bima Yojana (AABY): This is a social security scheme launched in 2017 to provide healthcare
facilities for rural landless individuals. The head of the household or earning member of a family will be
covered under the scheme (AABY). The beneficiary should be between 18 to 59 years of age.

The dependent of the beneficiary will receive Rs.30,000 upon natural death, Rs.75,000 upon accidental
death or permanent disability, and Rs.37,500 on partial disability.

Janashree Bima Yojana (JBY): This scheme was launched in August 2000. This scheme targets people
falling below the poverty line (BPL) in 45 occupational groups covered under the scheme.
Employment State Insurance Scheme (ESIS): This is a social security initiative aimed at providing socio-
economic protection to the working class and their dependents. The scheme ensures that all member and
their family will receive full medical care from day one.

Universal Health Insurance Scheme (UHIS): The Indian public sector insurance companies have
implemented this scheme to improve the access to healthcare for poor underprivileged families.
Beneficiaries will receive reimbursement for medical expenses up to Rs.30,000 and accidental death cover
up to Rs.25,000. The insurance premium for this scheme is Rs.200 per person, Rs.300 for a family of five,
and Rs.400 for a family of seven.
2.10 Challenges faced by Health Insurance
In India, the Healthcare insurance is provided in three forms;

Commercial insurance (health covers, maternity covers, accidental covers, etc.)

Government welfare schemes, completely taken care of by the government where the beneficiary does not
have to pay to avail the schemes benefits

Health schemes which are part insurance and part welfare where the beneficiary has to pay some nominal
premium to avail the benefits (Rashtriya Swasthya Bima Yojana).

Despite the endeavours towards expanding the horizon of healthcare in India, the out of pocket expenditure
on healthcare is about 85.9 (according to 2013 World Bank data). Out of pocket expenditures of countries
with comparable backgrounds and economic growth such as Indonesia and Malaysia stands at 75.1% and
79.9% respectively. As opposed to this, countries such as France and Canada have recorded significantly
lower out of pocket expenditures at 32.9% and 50.1% respectively (World Bank).

Low penetration of healthcare services and insurance leads to various difficulties such as reach and
accessibility, literacy levels and information penetration, and mindset and cultural practices. Escalating costs
of healthcare services and unavailability of competent medical professionals, equipment, infrastructure, and
medicines are also huge challenges.

On an average, people of the country end up spending a major portion of healthcare needs from their pockets
because in India only tertiary healthcare needs (hospitalization) are covered under any kind of health
insurance. A visit to the physician or a sonography “primary and secondary outpatient healthcare services
are not covered under most health insurance options and the patient has to pay from his or her own pocket.

It may be mentioned that insurance schemes or policies can be utilized in India only when the patient spends
24 hours on a hospital bed.
2.11 FACTORS THAT AFFECT YOUR HEALTH INSURANCE PREMIUM
When you purchase an individual or family health insurance policy through the HealthCare.gov
marketplace, directly from an insurance company, or through your employer, the premium is the amount you
pay each month for the policy.

Even if you never go to the doctor or use any health care services, you have to pay your premium to keep
your coverage. In the past, insurance companies could use a lot of information about you – including your
weight or body mass index, your family history, and your profession – to determine what to charge you.

Now, thanks to the ACA, insurers can use only five factors when deciding how much your premiums will
be.

1. Your Age
As you get older, you’ll likely see your insurance premiums start to climb. My mom used to
complain that her health insurance premiums were in the $700 range compared to the $300 premiums
I was paying as a 30-something.
HealthCare.gov notes that older people often pay premiums that are three times higher than those
charged to younger people.
Although it might seem unfair, charging older people a higher premium makes sense from an
economic standpoint. Older people tend to use more health care services than younger people, as
there’s an increased chance of developing a chronic condition as you age. Of course, if you’re a
healthy 60-year-old who only ever needs to see your doctor for your annual check-up, it’s natural to
feel disgruntled about having to pay $700 or so per month.
2. Your Location
Just as a person living in San Francisco or New York is likely to pay more in rent than a person
living in Kansas City or Memphis, where you live also affects how much you pay in health insurance
premiums.
The rules of your state or municipality affect your premiums, as does the amount of competition in
the area. If many health insurance companies are competing for your business, better premiums are
usually available compared to if you lived in an area where there’s only one option.
3. Who’s Covered by the Plan
The more people your health insurance plan covers, the higher your premiums are. Don’t let a higher
monthly premium keep you from getting the coverage your family needs, though.
You also don’t necessarily want to have each person purchase their own plan. You and your spouse
will probably pay less overall if you purchase a family plan instead of individual plans.
4. If You Smoke or Use Tobacco
Although the ACA dramatically limited the things insurers could charge more for, one of the
surcharges it kept was the tobacco surcharge. If you smoke, use tobacco, or have used tobacco within
the last 12 months, an insurance company can increase your premium.
Depending on the company, the surcharge can be up to 50% of the cost of the premium. For example,
a policy might cost someone who isn’t a tobacco user $300 per month. With the tobacco surcharge,
the same plan would cost a smoker up to $450 per month.
The tobacco surcharge is controversial. Its goal seems to be to encourage people to quit smoking for
financial reasons, but a study published in the journal Health Affairs suggests that hasn’t happened.
Instead, people who smoke seem less likely to purchase insurance in the first place.
5. The Type of Plan You Choose
When choosing a plan, there are typically several categories available. Health insurance plans are
rated based on the amount of coverage they offer and your total out-of-pocket expenses. Generally,
the less you pay out of pocket for health care services, the higher your premium.
Under the ACA, there are four categories of health insurance plan:
Bronze.
Bronze plans have the lowest monthly premiums but the highest out-of-pocket expenses.
Deductibles are often over $6,000 if you purchase a bronze plan. That said, if you rarely or never
need to see a doctor for anything beyond preventative care, a bronze plan usually makes the most
sense.
Silver.
Silver plans have a somewhat higher monthly premium than bronze plans but also have slightly
lower out-of-pocket expenses. If you do see a doctor for anything beyond routine preventative care
but don’t have a chronic condition, a silver plan is often the most cost-effective option. For example,
if you typically see your doctor when you have a sinus infection or sore throat, you might choose a
silver plan.
Gold.
With a gold plan, monthly premiums are quite high, but out-of-pocket expenses are much lower
when you go to a doctor or need other forms of health care. If you need a lot of medical care or have
at least one chronic condition, a gold plan might be the right pick.
Platinum. Platinum plans have the highest premiums but the lowest deductibles and out-of-pocket
expenses. In some cases, your medical costs are entirely covered by your premium payment under a
platinum plan. You might want a platinum plan if you see a doctor for multiple conditions or have
above-average medical expenses.
A fifth category – catastrophic plans – also exists, but it’s only available to people under age 30 or people
with a documented financial hardship. If you’re in your 20s, are in generally good health, and don’t have a
lot to spend on a health insurance plan, a catastrophic plan might be a good option. Catastrophic plans have
the lowest monthly premiums but the highest deductibles.

2.12Factors That Don’t Affect Your Health Insurance Premiums

Once upon a time, insurance companies had a lot more control over how much they charged you for your
health insurance. Luckily, some of the criteria used in the past no longer have any effect on your monthly
premium.

1. Your Sex
Women used to have higher monthly premiums than men. One report from the National Women’s
Law Center found that some policies charged women rates that were more than 80% higher than the
premiums charged to men.
The argument was that women were more likely to see a doctor and use health care services than
men, so they should pay more – a practice colloquially known as the pink tax. Along with having to
pay higher premiums, women also often faced higher out-of-pocket expenses, as many women-
specific services, such as maternity care and birth control, weren’t covered by many plans.
The ACA prohibits charging more for health insurance based on a person’s sex. As the icing on the
cake, many “women-only” health services are now considered preventative care and must be
provided to you at no additional charge as long as they’re provided by a doctor or medical
professional in your insurance company’s network. Among the covered services are Pap tests, birth
control, mammograms, and prenatal care.
2. Your Health
Another big change under the ACA is that your current health can’t affect your premiums or access
to health coverage. Back in the day, insurance companies could either charge people more for
coverage if they had a preexisting medical condition or could refuse to cover the costs of treating that
condition. In some cases, insurers would turn a person down because they had a condition such as
diabetes, cancer, or asthma or simply refuse to cover the costs of treating that condition.
Fortunately, those days are over. If you have or develop a chronic or serious condition, you don’t
have to worry that your insurance costs will go up. Nor do you have to worry about being denied
coverage.
2.13 Other Things to Consider When Choosing a Health Insurance Plan

 Your monthly premiums are one thing to consider when picking out a health insurance plan. But they
aren’t the only thing. It’s also important to make sure your insurance plan meets your coverage and
health care needs. Otherwise, you’ll end up paying more out of pocket than you need to.
 Other things to think about as you evaluate your health care plan options include:
 Network:
 Insurance companies typically have networks of doctors and health care providers who contract with
them and agree to accept lower rates they’ve negotiated. Ideally, your current medical team will be in
the insurance company’s network. If not, you’ll have to change doctors or pay more out of pocket.
 Health Savings Account:
 Some insurance plans with high deductibles give you the option of opening a health savings account
(HSA) through a company like Lively. The money you deposit into an HSA is tax-deductible,
reducing how much you owe in income taxes. But the funds you deposit must be used for medical
care.
 Prescription Drug Coverage:
 If you take prescriptions, find out what sort of prescription drug coverage each plan offers and
whether it covers name-brand drugs or only generics.
 Plan Type:
 When choosing a health insurance plan, you’re likely to see a lot of acronyms: HMO, PPO, EPO.
We’ll go into more detail on these in the next section.
 Cost of Co-Pays, Deductibles, and Co-Insurance. Depending on the type of plan you choose, you
might have several different types of out-of-pocket expenses. A co-pay is the amount you pay at the
time you see a doctor. It can be $10, $50, or another amount. The deductible is the amount you need
to pay for care before your insurance starts providing coverage. Depending on your plan, it can be a
few hundred dollars or several thousand. Co-insurance is the portion of your medical costs you’ll
have to pay after you’ve paid the deductible. All three affect the total cost of your health care.
 Your Health Care Needs:
 Your health care needs won’t necessarily always be the same. You can’t necessarily predict a chronic
condition diagnosis. But there are things you can anticipate, such as whether you’re planning to
conceive over the next 12 months.
 CHAPTER -3

LITERATURE REVIEW

When a person experiences a bad shock to health, their medical expenses typically rise and their contribution
to household income and home production

(e.g. cooking or childcare) declines (e.g. Wagstaff and Doorslaer, 2003; Gertler, Levine & Moretti, 2003;
Gertler and Gruber, 2002).

According to the WHO,

Each year, approximately 150 million people experience financial catastrophe, meaning they are obliged to
spend on health care more than 40% of the income available to them after meeting their basic needs.

(WHO Factsheet N°320, 2007) Low income and high medical expenses can also lead to debt, sale of assets,
and removal of children from school, especially in poor nations.

A short-term health shock can thus contribute to long-term poverty (e.g. Van Damme et al, 2004; Annear et
al, 2006).

At the same time, because households often cannot borrow easily, they may instead forego high-value care.

When they do access care it will often be of low quality (Das, Hammer and Leonard, 2008), which can lead
to poor health outcomes.

Theory suggests that health insurance can address some of these problems. By covering the cost of care
after a health shock, insurance can help to smooth consumption, reduce asset sales and new debt, increase
the quantity and quality of care sought, and can improve health outcomes. Unfortunately, rigorous evidence
on the impact of insurance is scarce, and there are even fewer studies on the effects of insurance in
developing countries. One reason for the lack of evidence is that it is difficult to find a valid control group
for the insured. We cannot simply compare the outcomes of insured and uninsured households, since health
insurance status is typically strongly correlated with other household characteristics. For example, rich and

well educated households typically have both better health (Asfaw, 2003) and better health insurance
coverage (Jütting, 2004; Cameron and Trivedi, 1991), but the positive correlation between health and
insurance status tells us nothing about the impact of insurance. On the other hand, those in poor health may
be more likely to pay for health insurance (Cutler and Reber, 1998; Ellis, 1989), but finding that the insured
tend to be sicker would not imply that insurance causes illness.
Below we review past evidence on the impacts of health insurance, focusing on studies where health
insurance status is plausibly exogenous, or where studies have attempted to eliminate bias due to self-
selection. A majority of the rigorous studies are based on United States data. We follow Levy and Meltzer
(2004, 2008) in both our choice of U.S. studies and in our main conclusions.

Standard insurance theory predicts that insurance markets will suffer from adverse selection, which occurs
when less healthy people or people who are more-risky with their health are more willing to purchase health
insurance because they know that the amount, they spend on healthcare will be larger

than the premium they will pay. (e.g., Rothschild and Stiglitz 1976; Akerlof, 1970) Voluntary health
insurance cannot be financially sustainable if adverse selection is severe, since only the most-costly patients
would find it worthwhile to purchase insurance, and premium levels will not be able to cover the high costs
of care.

Some studies in wealthier nations find evidence that people with higher expected medical expenditures
(measured in a variety of ways across studies)

are more likely to buy insurance or pay for health insurance at higher premiums

than those with lower expected medical expenditures (e.g. Cutler and Zeckhaus, 1998). However, the extent
of adverse selection in health and other insurance is often found to be minimal (e.g. Wolfe and Goddeeris,
1991; Finkelstein and Poterba, 2004) or non-existent (e.g. Finkelstein and McGarry, 2006; Cardon and
Hendel, 2001; Cawley and Philipson (1999). There is also some recent evidence of positive selection into
health insurance (e.g. Fang et al., 2008).

The literature review suggests that income is one of the important determinants of purchase of health
insurance (Scotton 1969, Cameron, Trivedi et al. 1988, Savage and Wright 1999). Income has been found
to be having a positive association with health insurance purchase decision consistently in different
studies conducted in different countries Propper (1989) in UK; Cameron, Trivedi et al. (1988)in
Australia and Hurd and McGarry (1997) in USA, Healthcare expenditure is another important variable
affecting health insurance purchase (Kronick and Gilmer 1999). Relation of health insurance purchase
decision and health expenditure is based on the premise that families which have higher chances of requiring
hospitalization will have higher probability of buying health insurance.

Some other socio-economic factors like age, education etc. have also been found to be important factors
affecting health insurance purchase In India knowledge and awareness about health insurance could be
important factor for health insurance purchase decision. Very few studies have tried to analyze reasons for
low penetration of health insurance in India (Wadhawan 1987, Ellis 2000, Bhat and Mavalankar
2001).
Some studies have tried to analyze community-based health insurance in India. (Devadasan, Ranson et al.
2004, Ahuja 2005. Rao (2004) discusses the issues and challenges for health insurance sector in India.

These and other studies have tried to analyze health insurance sector in India, but not much systematic
empirical work has been done and this area is largely unexplored.

The theory of risk has been applied extensively to the literature related to health insurance decision (Arrow
1963; Feldstein 1973). Under conditions of consumer rationality and risk averseness, the decision to
purchase insurance is made on the basis of expected utility gain. Health Insurance choice essential decision
whether or not to purchase private health insurance (Barrett and Conlon 2003). Binary discrete choice
models using either legit or probit has been used to analyze determinants of this type of purchase decision.

Cameron and Trivedi (1991) specified a conditional expected utility function that is associated with
alternative health care regimes. The consumer chooses the regime that maximizes expected utility The
utility gains, expected from the purchase of private insurance are related to the expected medical need of the
people in the first instance. Some individuals face greater risk vulnerability than others due to their age, pre-
existing health status, job profile and marital status.

For example, Hopkins and Kidd (1996) suggest that the probable distribution of future health states is based
on present and past Health status, Health care expenditure of the household may be another proxy of health
status of the household this view of the role of education in Health. Health status of the household This view
of the role of education in health decision-making has been well documented by Grossman (1972) and
Muurinen (1982).

The implication is that not only is a better educated person likely to be healthier which would lower the
probability of insurance, but also, he/she is likely to be better informed about both the services available in
the public hospital system and the benefits of joining a private health insurance fund. The indirect effect of
education is and the benefits of joining a private health insurance fund its impact on income. Education and
income are generally positively correlated (Van De Ven and Van Praag 1981).

Higher income generally decreases the opportunity cost associated with the purchase of private health
insurance. Overall, increases in both income and education would be expected to lead to an increase in the
probability of buying the insurance. Another set of factors which are found important in the literature of
health insurance are demographic and economic variables. These variables are employment, age, marital
status and gender. The available evidence suggests that socioeconomic variables act on choice in the
expected ways.
Those who are employed and those in executive positions are likely to purchase insurance (Butler 1999;
Savage and Wright 1999).

Married respondents are more likely to take out coverage (Cameron & McCallum 1995), though family
size apparently has been of little influence on the purchase decision (Cameron and Trivedi 1991).

PERCEPTION OF CUSTOMERS

The perception of individuals towards the risk is also an important factor. A consumers’ knowledge of being
at risk by being a member of a particular group of people with high-risk characteristics (e.g., those who
know they have high cholesterol) likely to influence their insurance decision. Hopkins

and Kidd (1996) and Butler (1999) found that smokers are less likely to purchase insurance. Smoking
behavior is viewed in these studies as a proxy for risk-aversion. Of the other possible determinants of the
decision to purchase insurance, an obvious factor is price. However few studies have attempted to estimate
price elasticity of demand. This is because of lack of price information and also because of limited variation
in price in highly regulated health insurance market. To overcome this problem Butler (1999) constructed
effective prices ‘from information on insurance fund premium revenue (averaged over policies sold) and the
expected benefits paid out by age category. The studies in Indian context on health insurance are scanty.
Several recent paper and reports have critically reviewed the Indian health delivery and financing system
(Bhat and Mavalankar 2000, Berman and Khan 1993, World Bank 1995, Planning Commission 1996, etc.).
These studies have documented issues and challenges the system faces in terms of accessibility, efficiency
and quality of the health care delivery.
RESEARCH GAPS

 The research was based on primary collection of data, there may be chances of human error and
bias.

 The research was dependant on the information provided by the respondents who were very
reluctant in providing right information and were careless.

 As associated with every project, time and money were the major limitations with project.

 Due to unwillingness of providing any information, the respondents filled the questionnaire
casually.

 The projection is purely based on verbal meetings with the respondents.

 Non-co-operative behavior of respondent was a big problem in this survey.

 While studying the report the above facts should be taken into consideration.
 CHAPTER-4

DATA ANALYSIS, INTERPRETATION AND PRESENTATION

4.1There are two types of methods of collecting data

1. PRIMARY

2. SECONDARY

PRIMARY DATA: The main purpose of collection of primary data was to prepared questionnaire. The
researcher tried to find out the awareness and Buying pattern of Health Insurance Through :

 Personal Approach
 Surveys
 Mails
 questionnaires
 articles, magazines
 telephone, discussion meeting with Managers, Agents of all the four Health Insurance companies
&customers etc. for this project personal interviews were conducted for collection
 SECONDARY DATA consists of published data collected through
 Books
 websites
 news papers
 journals
 magazines
 research papers
 primary data: the primary data for the research is collected from a survey in Mumbai
in Maharashtra, India. The sample size is 30 respondent for research. The parameter of
customer perspective is shown in graph and pie charts.

Questions

1 age

age

0-18 19-30 30-50 50-above

2 gender

gender

male female
3 marital status

marital status

prefer not to say

widow

divorced

seperated

married

single

0 5 10 15 20 25

marital status

4 type of family

type of family
25

20

15

10

0
nuclear joint

type of family
5 education

education

illetrate primary middle matric higher secondary

graduation under graduate post graduate others

6 occupation

occupation

full time employement part-time employement unemployed

self-employued home-maker syudent
retired military
7 income per annum

income per annum,

9

0
less than 50000 50,000-1,00,000 1,00,000-1,50,0001,50,000-2,00,000 above 2,00,000 no answer

income per annum,

8 do you know about health insurance?

do you know about health insurance

yes no
9 if yes what are the sources of information

sources of information
14

12

10

0
tv newspaper agents family friends movies employees tax others
of consultants
insurance and doctors
companies

sources of information

10 do you have health insurance?

do you have health insurance

30

25

20

15

10

0
yes no

do you have health insurance

11 who is your insurer

who is your insurer

public company private company others no answers

12 what type of health insurance you have

type of health insurance

individual health insurance group health insurance family floater health insurance
other no answer
13 which insurance company you would prefer

which company you would prefer

20
18
16
14
12
10
8
6
4
2
0
public private others no answers

which company you would prefer

14 who persuaded you to purchase health insurance

Series 1
14
12
10
8
6
4
2
0

Series 1
15 what are the chances of renewing the service after the expiry of present health insurance plan

chances of renewing plan

100% 50% 25% 0% no anwers

Secondary data

4.2 POTENTIABILITY OF THE MARKET

India is about 1.2 million of population and granting that not all may not be insurable for various season, it
makes a strong case for potentiality of at least 50 crore plus people to be under some health insurance
scheme apart from government schemes for the weaker sections. Unfortunately, even after opening of
market the penetration has been poor and roughly only about 3.5 crore people are covered under various
insurance scheme as mentioned above making the market quite big, only being scratched at the surface
without being properly tapped. However, since last 2/3 years health insurance has picked up with aggressive
selling coupled with awareness making it the second largest portfolio after motor Insurance.

4.3 IMPACT OF HEALTH INSURANCE ON STRUCTURAL AND QUALITY OF

PRIVATE PROVISION

The experiences in liberalizing the private health insurance suggest that it has undesirable effects on the
costs of health care. The costs care generally goes up. Given the present system of fee for service and
current scenario of health infrastructure in private sector, the development of insurance will need
improvements in the quality and change in structure. The new investment to improve quality will result in to
high cost and therefore increase in prices of Insurance products. There would be development in the
direction of exploring options of managed care, which would help in reducing the costs. The

developments would be needed in the direction of exploring options of managed care, which would help in
reducing the costs. The developments would be needed in the directions of strong information base
accreditation system for providers. The structure of the health sector will have to change from multi-single
doctor hospitals and clinics to large hospitals and polyclinics which provide services of multiple specialties
and can operate at larger scale. This will aloe them to provide high quality professional care at competitive

prices.

As one of the responses to these Third-Party Administrator (TPA) are rapidly emerging in India. Here we
can learn from the models, which we have emerged elsewhere. but their applicability to Indian situation
needs to be examined carefully. These aspects of the health sector will need detail study. Lack of adequate
information base to operate insurance schemes at large scale. The insurance mechanism prevalent in many
developed countries has their history. Health reforms experiences in many countries are replete with the
suggestion that the systems cannot replicated easily
4.4 ADVANTAGES OF HEALTH INSURANCE:

Now a days there are different insurance policies coming in the market like life insurance, vehicle insurance,
but the importance of health insurance seems to be growing at a very fast rate. Health insurance is mainly
taken to protect a person from any unexpected medical expenses incurred due to any illness.

With the present condition, it is observed that with the latest technologies or the advancements taking place,
the health care has immensely improved but so has the expenses. The treatments are becoming more and
more expensive with each passing day. It is required that every individual gets a financial security related to
any unexpected medical expenses coming his way. The main merits observed in health insurance are:

1. Medical cash benefits- this benefit entitles you to get cash benefits, if you are hospitalized. All the
financial expenses incurred would be covered in this plan. The amount provided to you will be on per day
basis and the amount depends upon the plan you have opted.

2. Cashless facility- in this benefit, you can get hospitalized on the basis of this plan without paying a penny.
But this benefit can be availed only in some special cases. Sometimes the amount paid by you, is reimbursed
within 24 hours.

3. Before and after expenses- as per this policy all the expenses related to illness incurred 60 days prior to 90
days after hospitalization would come under the cash benefits that you can avail.

4. Floater benefits- this is an add-on benefit for the health insurance policy holders. In this policy, an
individual can take a single policy for the whole family which would cover the entire member in a single
sum assured.

5. Other benefits- the policy holder is entitled to a 5% of bonus amount of the sum assured every year as a
bonus. This policy includes, all the expenses including the ambulance charges, health checkups to the
maximum limit of Rs 1000 per family. It even provides tax benefits as per income tax act. Considering all
the aspects, health insurance has advantages which could be availed very easily. The health insurance is
needed now more than ever due to skyrocketing medical expenses, the increasing possibilities of diseases.
So, if you still don‘t have a good health care plan, just go for it at the earliest
4.4 MAIN IMPORTANT FEATURES OF HEALTH INSURANCE:

Though the features may vary from insurer to insurer, some basic features are:

1. Reimbursement for Hospitalization due to illness/disease/ surgery.

2. Reimbursement for Domiciliary Hospitalization expenses in lieu of Hospitalization

3. Pre-hospitalization Expenses

4. Post-hospitalization Expenses

5. Ambulance Charges

6. Cashless Access

7.Income Tax Benefit etc.

Insurance may be described as a social device to reduce or eliminate risk of life and property. Under the plan
of insurance, a large number of people associate themselves by sharing risk, attached to individual insurance
plan that exclusively covers healthcare costs and is called Health Insurance. Since the past two decades,
there has been a phenomenal surge in acceleration of healthcare costs. This has compelled individuals to
have a relook on their actual monthly expenditures, spending patterns and simultaneously allocate a
proportion of their income towards personal healthcare. This has resulted in individuals availing healthcare
insurance coverage not only for themselves but also for their family members including their dependants. In
short, healthcare insurance provides a cushion against medical emergencies. The concept of Insurance is
closely concerned with security. Insurance acts as a shield against risks and unforeseen circumstances. Some
major health insurance companies in India include National Insurance Company, New India Assurance,
United India Insurance, ICICI Lombard, Tata AIG, Royal sundaram, Star allied health insurance,
cholamandalam, DBM, Bajaj Allianz, Apollo, AG Health Insurance company among others Categories

Indian Health Insurance is primarily classified into 2 categories:

•Cashless Hospitalization
• Medical Reimbursement

a) Cashless Hospitalization

Cashless hospitalization is a specialized service provided by an insurer wherein an individual is not required
to pay the hospitalization expenses at the time of discharge from the concerned hospital. The settlement is
done directly by the insurance company (or insurer). However, prior approval is a must from the TPA (Third
Party Administrator) before availing the benefits under this option.

4.5 CASHLESS HOSPITALIZATION CAN BE OF TWO TYPES

Planned hospitalization:

This is a planned hospitalization wherein the insured is aware of the hospitalization in advance. This
duration period may vary from case to case. Examples include: FTND (Full Term Normal Delivery),
Chemotherapy treatment for carcinoma (cancer), for cataract surgery, tonsillectomy (removal of tonsils).

• Emergency hospitalization:

It is a sudden hospitalization that may be either an emergency or due to unforeseen circumstances. In short,
hospitalization is not anticipated in advance. Examples include RTA (Road Traffic Accident), Myocardial
infarction (heart attack), Acute Appendicitis.

b) Medical Reimbursement

Re-imbursement means to repay or to compensate. Thus, Medical Reimbursement means to repay the
products/services availed during hospitalization more importantly after the completion of the treatment.
Under this procedure, the insured has to bear the entire expenses incurred during hospitalization. After
getting discharged from hospital, the insured/policy holder can claim medical reimbursement. For availing
benefits under this option, the insured has to approach the concerned TPA under which he/she is covered, fill

the requisite form and satisfy all the requirements as mentioned. This includes submission of TPA card,
policy paper, discharge summary, prescriptions, diagnostic laboratory reports, OPD treatment details etc. A
sum is granted as reimbursement for treatment expenses.

A recent survey conducted in 2008 showed that only 3% of the entire Indian population has availed some
sort of insurance policy and enjoys benefits included under its coverage. This miniscule percentage
constitutes both – PSUs (Public Sector Undertakings) and Private Insurance Companies. Since, the general
public are by and large ignorant about the benefits of availing healthcare insurance policies, there lies an
urgent need to educate the masses regarding the importance of Health care insurance and the benefits
derived on account of it. There are numerous reasons for not availing health insurance. There is a lack of
knowledge regarding the existing insurance products/services in the markets. On top of it, there are
numerous misconceptions about Insurance prevalent in the Indian Markets. In India; public funded
healthcare is available only to a miniscule section of BPL (Below Poverty Line) groups, low income groups
and to government employees. The Indian Government has formulated Employee State Insurance Scheme
(ESIS) that focuses on the public healthcare policy for low-income groups.

The government employees can avail Central Government Health Scheme (CGHS) that offers medical
treatment at a subsidized cost.

With the opening up of insurance sector for private participation, numerous players have entered the
healthcare segment, but inspite of the entry of private sector, penetration of insurance coverage in India is
abysmally low. Recently a legislature has been passed in the Indian Parliament allowing 49%of FDI in
Insurance Industry.

4.6 MAIN FUNCTIONS OF HEALTH INSURANCE

The primary function of Health Insurance is to pay those covered expenses, as outlined in the policy,
incurred as a result of an accident or illness. It often has two elements, one being hospitalization expenses
and the other being for the medical care rendered by a physician or other health care professional. The vast
majority of health insurance is employer-based, meaning that people have access to it through their
employment. Not all employers offer it, and for those whose employers do not, they are free to obtain
individual/family policies on their own.

Health insurance comes in a variety of types. These include traditional indemnity plans, which are becoming
less common, and an array of managed care plans, including Health Maintenance Organizations and
Preferred Provider Organizations. Both of the latter provide medical care on a prepaid basis, but differ in
their delivery models, including by the degree of choice of provider that he member retains.

Most health insurance plans have deductibles and co-payments, although different terminology may be used.
A deductible is an amount that the insured/member must pay before the insurer's liability for payment is
triggered. A co-payment is a form of cost-sharing such that the insurer pays a percentage of a covered
expense, and the insured pays the remainder. The size of the deductible and co-payment has an impact on
premium. Insurance may be described as a social device to reduce or eliminate risk of life and property.

Under the plan of insurance, a large number of people associate themselves by sharing risk, attached to
individual insurance plan that exclusively covers healthcare costs and is called Health Insurance Since the
past two decades, there has been a phenomenal surge in acceleration of healthcare costs. This has compelled
individuals to have a re-look on their actual monthly expenditures, spending patterns and simultaneously
allocate a proportion of their income towards personal healthcare. This has resulted in individuals availing
healthcare insurance coverage not only for themselves but also for their family members including their
dependants. In short, healthcare insurance provides a cushion against medical emergencies. The concept of
Insurance is closely concerned with security. Insurance acts as a shield against risks and unforeseen
circumstances. In general, by and large, Indians are traditionally risk averse rather than risk lovers by
Nature.

4.7 MAIN IMPORTANT TYPES OF COVERAGE OF MEDICLAIM

A) HMO (Health Maintenance Organization).

You go to your family doctor for any health services. If there is urgency in going to a specialist, your family
care doctor will help you in referring one. Mediclaim companies will not insure you without the referral
from your family doctor and therefore, you will have to pay yourself for such specialist services.

B) PPO (Preferred Provider Organization Plan).

Through this plan you can analysis to any primary, specialist, or medical facility without referral and get
totally covered. It is the Mediclaim companies that cover you when your child breaks a bone accidentally
and you approach directly to the orthopaedic doctor, without consulting your primary doctor.

C) POS (Point of Service).

This plan essentially includes both an HMO and a PPO plan. Mediclaim companies give you the option from
the two plans for every medical case. The plan offers extra covered preventative programs, however, you
may have to pay more from your pocket, if you choose a doctor outside your plan.

D) HSA (Health Savings Account).

This plan is much more superior than the above mentioned mediclaim plans. The plan covers eyeglasses,
dental, cosmetic procedures, over-the-counter medications, etc. It is a tax-deferred savings account as long
as withdrawals are concern for medical expenses. Funds outstanding at the end of the year are carried
forward into an IRA account
4.8 DIFFERENT KINDS OF HEALTH INSURANCE

1. Individual Mediclaim Policy

This is the plain vanilla mediclaim or health insurance policy for an individual protecting this person from
the expenses incurred due to disease or injury.

2. Floater Policy

A floater health insurance policy covers your entire family under one policy with one sum insured and one
premium. It covers all the expenses as covered under mediclaim only the cover is now extended to the
family instead of one person. This cover can be used by any member of the family any number of times. The
advantage of this policy is that saves money by spreading the cover across family members

3. Critical Illness Policy

Insurance companies define certain specified illness or diseases as ―critical . If you have a critical illness
policy, then the insurance company will pay you a lump sum payment if you are diagnosed with a critical
illness as defined by the insurance company. Some of the diseases/conditions which are usually deemed
critical are Cancer, Heart Attack, Kidney Failure, Major Organ Transplant, Stroke, Paralysis and Heart
Valve Replacement Surgery. (For a more comprehensive list check with your insurer)
Unlike other general insurance policies, these policies come with multiple options in terms of sum assured
and term of the policy. For example ICICI Lombard provides critical cover for 5 years for a Rs. 12, 00,000
coverage. These policies are also available with disability coverage to ensure that you are also covered for
loss of income during that critical period.

3.Overseas Mediclaim Policy

An Overseas Mediclaim Insurance policy provides cover for medical expenses incurred abroad for treatment
of illness and diseases contracted or injury sustained during the insured period of overseas travel. Anyone
who is travelling abroad for business or pleasure or for educational purposes should have this policy.

4. Student Medical Insurance

Student Medical insurance covers the cost of health care while studying abroad. It is an essential requirement
of many foreign universities for its overseas students. Students are generally advised to buy it in India as it is
substantially cheaper than buying it abroad.

5. Tax Saver

This is a new class of insurance launched to take full advantage of the income tax benefit under section 80 D
of the Income Tax Act 1961. The premium is fixed at Rs 15,000 for all plans. For Senior Citizens aged 65
and above, the premium is Rs. 20,000 This plans includes reimbursement of OPD expenses up to Rs. 10,000.
This includes diagnostics tests, dental treatment and related expenses. This insurance is
suitable for people who are looking to cover all their medical expenses in a tax-free manner

4.9 ESSENTIAL GUIDELINES FOR AVAILING HEALTH INSURANCE

POLICY:

The following points should be borne in mind while purchasing an

Individual health policy:

• Understanding the policy coverage: The policyholder should be able to clearly comprehend the extent of
medical coverage being offered under the particular health insurance policy before opting for it. The
individual should check whether pre-existing diseases and its resultant complications are covered or not, as
well as the extent of the coverage under that particular policy.

• Keeping an eye for medical expenses that are not covered/re-imposable under the policy: Before availing a
particular health insurance policy, the prospective policyholder should note the medical expenses not
covered under that Insurance policy. It is important to note that deductibles are a part and parcel of any
insurance coverage and the expenses incurred as part of the medical treatment need to be borne by the
individual. Generally this list includes aprons, sterilization charges, gloves, Dettol, gloves etc.

• To understand whether it is a co-insurance policy: Before availing a health policy, the prospective
customer should understand whether it is a coinsurance policy or not. It is advisable to get an individual
health insurance policy with a co-insurance payment option. The maximum amount does not exceed 15% of
the entire medical coverage for a particular disease.

• Understanding and updating oneself about expiry period regarding the policy cover: An individual health
insurance cover entails regular premium payments on a monthly, half yearly or annual basis before the
expiry of a particular policy. Non-payment of premium within the stipulated time results in the lapsing of the
policy with subsequent break in the policy coverage of the concerned individual. Even though the concerned
individual holds policy with an Insurance company for many years together, a break in the policy coverage
Which generally does not exceed more than 15 days is treated as fresh policy cover.
4.10 AWARENESS HELP TO BOOMING HEALTH INSURANCE IN INDIA

In the Indian non-life insurance industry, health insurance is the second largest segment. It has picked up
pace in previous fiscals, and is set to reach new heights in the coming few years as public and private
insurers are coming up with various schemes to cover the untapped insurance market. As per our latest
findings, the Indian health insurance industry is one of the most prolific ones in the world. As the healthcare
costs and awareness are rising in the country, we expect the segment to grow with gross premiums scaling
up at a CAGR of around 32.5% during 2010-11 to 2013-14.

India‘s health insurance landscape has undergone tremendous changes in the last few years with the launch
of several health insurance schemes, largely initiated by central and state governments. We observed that a
significant share of coverage has been achieved through central and state government-sponsored health
insurance schemes. Besides, private and public health insurers have introduced a large number of plans and
schemes to cover an individual and his family against critical ailments like heart failure, stroke and kidney
failure.

As a chunk of population in India is living with HIV/AIDS, the private health insurance companies are
cashing in on the big opportunity by designing special policies for such people. India could soon see a
national medical insurance policy for people living with HIV (PLHIV). The National Aids Control
Organization is planning to make insurance 'inclusive and universal for PLHIV', we observed while studying
and analyzing trends in the Indian health insurance industry.

During the health insurance market analysis, researcher found that there are around 28 active third party
administrators (TPAs) in India, and the TPA infrastructure in the country has witnessed a strong growth with
the rising penetration of health insurance. The TPAs are recognized as valuable service providers in the
health insurance services delivery chain. Our comprehensive report also identified that emergence and
growth of health insurance have given rise to a need for maintaining and optimizing claims processing and
management. It aims at enhancing services, offered by health insurance companies, for the maximum benefit
of the insured.

According to the study, health insurance portability is also gaining popularity in India as it allows health
insurance policyholders to switch companies while retaining their no-claims benefit. The report also
provides an overview of the rural health insurance segment, and expects that the number of uninsured rural
households will decrease with time. Various Insurance Regulatory and Development Authority (IRDA) acts
and amendments have also been studied to understand the regulatory framework for the industry.

The research also looks into profiles of various players in public and private sectors to present the

competitive landscape and a balanced outlook of the Indian health insurance

industry to clients.

4.11 RULES BY IRDA

 All Health Insurance products henceforth would be renewable for lifetime, without any renewal
ceasing age.
 Grace period for renewal of Health Insurance would be 30 days, before which delay of renewal
could be condoned by the Insurance Company.
 Health Insurance policies from Life Companies would have a minimum term of 4 years, whereas
Non-Life companies could have a maximum term of 3 years.
 Clear procedures specified for smooth migration of children from Floater plans proposed by their
Parents, into their own independent plans.
 Insurers would be required to have policy wordings of all their products mandatorily put up on their
website. (Yes, there are some good companies which don’t have Policy Wordings on their portal)
 Communication of Denial of Coverage, and Loading on fresh Health Insurance proposals should be
in writing.
 Separate Claims and Grievance Cell for Senior Citizens.
 Loading on Claims only when individual claims for 3 consecutive years exceed 500% of the renewal
premium.
 Health Insurance Customers with multiple insurance policies, would have a choice to choose which
product he wants to use. Contribution would be affected between Insurance companies, without
involving the customer.
 Standard Definitions, Exclusions, and Forms (like Claim Forms) are expected to be released by
IRDA.
 Renewal Procedure (regarding maximum age, changes in coverage at later ages, upgrading cover,
loading charges) would have to be clearly detailed in the policy wordings
 Any change in Terms of the policy at the time of renewal need to be communicated with the policy
holder 3 months before the renewal date.
 Insurers are required to mandatorily settle claims within 30 days of submission of complete
documents.
 Insurance Companies cannot reject claims on technical grounds of delayed submission, if the
customer can provide valid reasons for the delay caused.
 Cashless Cards should be issued within 15 days of issue of the Health Insurance Policy. No Fresh
cards would be issued every year on. The same cashless card would be continued every year.
 Hospital Network would be the responsibility of the Insurance Company, and not the TPA (which is
the case currently) Insurance Companies would be required to make direct agreements with
Hospitals. These agreements could be tripartite with the TPA. In short, Insurance Companies would
 administer the network and would be held responsible for issues that arise in the network. (Since
TPAs were originally brought in to primarily administer the network of hospitals, their role after
these regulations take effect, would be diluted significantly.)
 Any Change of TPA in a policy should be informed to customer with 30days of such change. All
data should be seamlessly transferred to the new TPA, ensuring there is no hassle caused to the
customers.

4.12 THIRD PARTY ADMINISTRATION

A Third-Party Administrator (TPA) is an organization which processes claims or provides cashless

facilities as a separate entity. Seen as an outsourcing of claim processing, TPA processes claims for both
retail and corporate policies. The risk of loss incurred remains with the insurance company. The insurance
company usually contracts a reinsurance company to share its risk. An insurance company hires TPA to
manage its claims processing, provider network and utilization review. While some TPA operates as units
of insurance companies, most are often independent.

TPA is also involved in handling employee benefit plans such as processing retirement plans. Handling
healthcare or employee benefit claims requires using a specialized set of manpower and technology,
therefore hiring a TPA for the same is a more cost-effective method. The Insurance Regulatory and
Development Authority of India (IRDA) defines TPA as a Third-Party Administrator who, for the time
being, is licensed by the Authority, and is engaged, for a fee or remuneration, in the agreement with an
insurance company, for the provision of health services. TPA was introduced by the IRDA in 2001.

Being one of the prominent players in the managed care industry, it has the expertise and capability to
administer all or a portion of the claims process. The services include claims processing, premium
collection, enrollment and cashless processing. Insurance companies setting up its own health plan often
outsource certain responsibilities to a TPA. The TPA acts like a claim’s adjuster for the insurance company.
In some cases the insurance company sets up an entire department within their own company to act as TPA
as opposed to hiring a commercial TPA company.
4.13 ROLE OF TPA IN HEALTH INSURANCE

Large number of the health insurance companies in India suffer losses and have been doing so for years
together. The group health insurance profile is what may cause optimum leakage to the health insurance
companies in India. TPA was introduced through the notification on TAP Health Insurance regulation 2001
by the IRDA-their basic role is to function as intermediary between the insurer and the insured and facilitate
the cashless services of insurance. For this service they are paid a fixed percent of insurance premium as
commission. The commission is currently fixed at 5.6 percent of premium. The introduction of TPAs is of
great help and relief to the insurance companies, which have been searching for ways and means to get their
management expenses in line with the specifications laid down by the IRDA.

TPA is maintaining a database of policy holders and issue identity cards with unique identification numbers
to them. They also handle all the policy- related issues, including claim settlements for the policy holders
Insurance companies (insurers) can now outsource their administrative activities, including settlement of
claims, to third party administrators, who offer such services for a cost. The insurers remunerate the TPAs;
hence, policyholders receive enhanced facilities at no extra cost. Once the policy has been issued, all the
records will be passed on to the TPAs and all further correspondence of the insured will be with the TPAs
and not with the insurance companies

The TPA's are expected to provide value-added services to the consumers, like arranging ambulance
services, medicines and supplies, guiding policy holders for specialized consultation, and providing
information about 24- hour help lines, health facilities, bed availability, organization of lifestyle
management and well- being programs.

In the middle of 2010, the public sector health insurance companies, namely United India, New India,
Oriental Insurance and moreover National Insurance took a tough stand and penalized major hospitals
where such procedure were taking place. They eliminated these hospitals from the list from which cashless

medical services can be availed by the customers. This caused a lot of pain to the insured; however, the
industry woke up to the fact that insurance companies were being taken for a ride. The 4 public sector health
insurance companies then decided to float a TPA of their own and even do away with the middlemen who
were not falling in line. This action is likely to cut down the frequency of false claims creeping their
business. The move has acquired big support even from the private health insurance companies. The issuer
was not of the public sector health insurance companies alone as well as certain private sector companies
have done away with the practice of TPAs as well as used to process claims through in-house
representatives. The TPA undoubtedly aims to give the health insurance industry the required boost in India.
4.14 THE SERVICES PROVIDED BY TPA AR AS FOLLOWS:

 ID card: TPA provides ID cards to all their policyholders in order to validate their identity at the
time of admission.
 The TPA's undertakes "Pre-authorization" before a surgical procedure to ease claim processing
 24 hours customer support services: The TPA provide assistance through their 24 hrs call center that
provides information regarding policyholder's data, provider network, claim status, benefits
available with existing cardholder, etc. All these details are furnished on request.
 Cashless Hospitalization: Each policyholder is provided with a list of empaneled hospitals where in
he/she can avail cashless hospitalization.
 Claim Management: On behalf of the insurance companies TPA administers and settles claims for
hospitals and policyholders. policyholders have the privilege of expressing their grievances to the
concerned insurance company or at the consumer's court if they are not satisfied with the services of
a TPA.

4.15THE SPECIALIZED FUNCTIONS OF THE TPA INCLUDE:

 The TPA keeps and maintains all the records of medical insurance policies of an insurer.
 The TPA issues identity cards to all the policyholders. The policyholders will have to show the
identity cards to the hospital authorities before availing any services from the hospital.
 In case of a claim, policyholders will have to inform the TPA on a 24 hr toll- free line provided
by them
 After informing the TPA, the policyholder will be directed to a hospital where the TPA has a
tied-up arrangement. However, policyholders have the option to be admitted at another hospital
of their choice in which case, payment will be on reimbursement basis.
 TPA pays for the treatment; they issue an authorization letter to the hospital for the admission of
the policyholder in the hospital.
 At the point of discharge, all the bills will be sent to the TPA while they are tracking the case of
the insured at the hospital.
 TPA makes the payment to the hospital.
 TPA sends all the documents necessary for consideration of claims, along with the bills to the
insurance company.
 The insurance company then reimburses the TPA
4.16 CONDITIONS DEFINED BY IRDA FOR TPA

Before IRDA allowed the TPA‘s to formally enter in to the insurance market there were intermediaries who
were acting on behalf of the corporate and playing very similar role of present days TPA‘s. Corporate were
utilizing these agencies to help them make process of claim reimbursement easier and smoother for their
employees, Also these agencies were helping to market the insurance product available –mainly the
Mediclaim–to corporate. As regulation ,2001er IRDA, the following are the conditions, specified for the
TPA ‘s.

Conditions Defined by IRDA for TPA

 Only a company with share capital 1crore of registered under the companies Act. 1956 can
function as TPA
 An organization is desires to function as TPA shall license from the authority by make in a
application in writing in form TPA and accompanied with fees of RS 20000
 The Authority, on examination of the application and detailed furnished by the applicant, may issue a
license, if it satisfied that the applicant TPA is eligible to function as TPA
 Every TPA approved by the Authority shall pay a further Rs.30000(Rupees thirty thousand only) to
the authority as license fees before the license granted to it.
 A copy of agreement entered in to between the TPA and insurance company or an modification
thereof, shall be filed, within 15 days of its execution and modification.
 Every TPA shall appoint, with due intimation to the authority, from among its directors or senior
employees, a chief Administrator officer (CAO) Chief executive officer (CEO) who shall be
responsible for the proper day to day administration activities of the TPA
 Where the authority decides to issue a license to the applicant to act as TPA, it shall issue the same in
the form TPA-2
 Every License granted by the Authority to a TPA, shall remain in force for three years, unless the
authority decides, either to revoke or Cancel it earlier, as provided in these regulations. A license
granted to a TPA may be renewed for a further period of three years
4.17 STANDARD HEALTH INSURANCE MODEL

In graphical representation of working environment of insurance industry and role of TPA in the system. The
core product or service of a TPA is ensuring cashless hospitalization to policyholder. Intermediation by a
TPA is ensuring that policy holder hassle- free services. Insurance companies pay for efficient and cost-
efficient services and health care providers get their reimbursement on time. By doing this it is expected that
TPA ‘s would develop appropriate system and management structures aiming of controlling
costs,developing protocols to minimize unnecessary treatments, Investigations, Improvement quality of
services and ultimately lead to lower insurance premium. However; the system is currently going through
teething troubles. Cashless policies where the insurer directly pays the hospital bill to the health care
providers have not yet fully materialized. Other than the above diagram we can see that there are main three
stakeholders in the health insurance system. These are insurance companies, Health care providers and
customers. Other than these, two more parties which are important and involved in the process are of Third-
party Administrator and regulator. Important difference between health insurance and any other kind of
insurance there are more stakeholders than in the other type of insurance and this makes the whole process
more complex and difficult to control.

4.18 STRUCTURAL AND OPERATIONAL WORKING OF HEALTH INSURANCE

4.19 CLAIM MANAGEMENT

Health insurance claims management has evolved significantly in India over the past 10 years. Since the
introduction of Mediclaim in the mid1980s till the advent of TPAs in 2002, claims management focused
primarily on reimbursement claims. With the advent of cashless hospitalization, the entire claim process
changed. New processes, such as prior authorization became vital for providers and payers. Time, which was
not a crucial element in processing reimbursement claims earlier, all of a sudden became a vital parameter.
Frequently the patient was already admitted when an authorization request reached a TPA, this meant that a
response had to be given within 4-6 hours so the full treatment could commence. Authorization limit
enhancements were also sought as the treatment progressed or as the patient was ready for discharge, they
also required an urgent response. The early claim systems were ad-hoc applications, frequently improvised
upon to incorporate the ever-changing multitude of payers / providers requirements, customer expectations
and health insurance products. They were mostly reactive systems, supporting existing products and
practices and not designed to support future requirements. Thus, a peculiar chicken and egg scenario existed-
how could an insurer introduce a new product when systems to service it did not exist? A good claims
management system must service existing products well while having the in-built flexibility to support
products with new and unique features, such as outpatient coverage or products with a savings component.
Increased flexibility to incorporate on-the-fly modifications in benefits and processes, in-built intelligence to
standardize routine processes and rules-based prompts and alerts are now available in newer claims system.
Not only do they reduce manual intervention and improve process efficiencies, they can auto adjudicate and
process claims which meet all compliance parameters thus enabling claims staff to provide more time for
claims that require detailed analysis.

4.20 FEATURES OF EFFICIENT CLAIMS MANAGEMENT SYSTEMS

Over the next decade, the insurance industry will witness continuous evolution in health insurance products
and processes. The trend to move the claims function in-house may also be adopted by more insurers. This
will create a unique opportunity for claims system vendors who can offer systems and applications with a
high level of flexibility and automation. The starting point is a well defined and intelligent work flow
management module to ensure optimumwork routing and distribution, in-built escalation and strong
externalcommunication features (like auto letter generation for various scenario‘s or SMS gateway). The
ability to easily configure new products at a granular level is a vital requirement this enables the automation
of various validation checks on policy, claimant, benefits and provider. A product configure at or interacts
with a rules engine to define product benefits and exclusions to facilitate automated adjudication of claims.
Appropriate pre-processing edits before the adjudication can substantially increase efficiency and process
claims faster. . In fact in the U.S. auto adjudication rates of 65% to 85% are not uncommon, albeit a very
high percentage of these are simple primary care claims. Since new products will attempt to differentiate
themselves with new service models, the claims systems will require business process builder to build
operational workflow compatible with the product. In summary, the product configuration module, business
process builder and rule engine is already becoming the core of the new generation claims systems. Such
integrated solutions enable the claims teams to achieve significant automation of validation checks at the
policy and the product level including verification of benefit and coverage limits to streamline prior
authorization for cashless claims. Access to data in the policy administration system and provider module is
vital at this stage. Once the claim data is in the system, pre-defined rules and product specific processes can
be applied. After ensuring that all mandatory information is provided and is valid, the first step would be to
match the claim against the prior authorization. The second step would be to conduct checks for medical
appropriateness, compliance with provider contracts and variation from usual and customary practices.
Much of this can be automated through the use of standard treatment guidelines embedded in the system to
identify excessive or unwarranted billing item, therefore generating cost savings for the insurer. An ideal
claims management system should also include a fraud management module that identifies possible
fraudulent patterns based on policy holder profile, underwriting information and provider profile. Since
fraud or abuse patterns frequently reoccur, such a tool can be very useful. Once a claim has been processed
the claim payment process starts. Integration with payment gateways is a common feature now and
significantly simplifies this process when paying network hospitals. In case of non-network hospitals or
reimbursement claims, it helps to have a good cheque printing module. Finally, an effective claims
management system can provide excellent insight to management. Not only can past trends be identified and
leveraged, the vast amount of claims data can be combined with enrollment data to be efficiently used in
actuarial pricing and underwriting. In summary, underwriting and claims handling are two core functions of
an insurer and technology offers a lot to streamline both these functions. The recent advances in claims
system ensures that in a few years a significant portion of claims in India will be processed without any
significant manual intervention.

4.21 The procedure of planned / emergency hospitalization.

In case of planned hospitalization

 Contact the toll-free help-line number.

 Fax / submit the required documents. E.g. Doctor‘s certificate, etc.
 Obtain approval from the TPA.
 Obtain authorization for network / non-network hospitals.
 Avail health treatment.

In case of emergency Hospitalization

 Rush the patient to the hospital

 Patient avails treatment
  Family contacts toll free number provided by the insurer
 Family submits required documents. E.g. Doctor‘s certificate, etc
 Family obtains approval from the TPA
 Family obtains authorization for network / non-network hospitals
 Hospital bills are directly settled by the TPA

4.22 Non-cashless claim or claim reimbursement : filing claim

A non-cashless claim is when you avail treatment in hospitals that do not form part of insurer‘s network. In
such cases, you have to pay the hospital bills and subsequently claim reimbursement from the insurer.

4.23The procedure to be followed in case of claim reimbursement:-

Call toll free number and provide hospitalization details. Settle the hospital bills directly. Submit the
relevant bills / documents to the TPA.

4.24 Documents required for filing a non-cashless claim

The following documents are required:-

 Duly completed claim form

 Xerox copy of the policy
 Bills, receipts and discharge certificate/card from the hospital in originals
 Bills from chemists supported by proper prescription
 Receipt and pathological test reports from a pathologist
 Medical practitioner / surgeon prescribing the test.
 Nature of operation performed and surgeon‘s bill and receipt.

The claims are serviced at both network as well as non-network hospitals

4.25 Not covered under cashless and non-cashless hospitalization: How to prevent
rejection claim.

There are following rules to prevent rejection of claim: -

 Read the list of coverage and exclusions in policy wordings (which comes to you with the policy).
 Ensure that you declare all the pre-existing diseases at the time of enrolment.
 Do not claim for any hospitalization and diagnostic studies / investigation charges, which do not
confirm existence of an illness or injury that requires hospitalization.
 After filing the claim, make sure that maintain minutes of interaction with the insurer in black and
white.
  Understand the policy in detail. Be informed about the ‗Fine print, exclusions and details pertaining
to depreciation and deductions.
 Do not hesitate to ask details of deductions or rejection.

4.26 LIST OF HEALTH INSURANCE COMPANIES IN INDIA

A quiet revolution has swept through India’s health care sector in the past 5 years:- best evidenced in the fact
that now nearly 27% of the nations populations is in the insured. The Indian health care sector is projected
continue its rapid expansion, with the market value of $280 billion by 2020. There are lost of options as far
as insurance companies are concerned as both public as well private health insurance operators are offering
health insurance coverage.

1 APOLLO MUNICH HEALTH INSURANCE COMPANY LTD

It is a joint venture between Asia’s largest integrated healthcare provider Apollo hospitals Group and
Germany based Munich Health. The company works upon the thought of “Let’s Uncomplicated’ and offers
tailor-made mediclaim policies to individuals, family, senior citizen and corporate.

HDFC ERGO Health Insurance Limited (formerly known as Apollo Munich Health Insurance Company
Limited) is a Joint Venture between HDFC Ltd and Munich Health. HDFC Ltd is India’s leading housing
finance company of India based at Mumbai. Munich health is the primary health business division of leading
reinsurer Munich Re based in Germany. Munich Health holds 49% stake while

Best health plan for you and your family. Starting from ₹ 373/month VIEW PLANSHDFC holds 51% stake,
making HDFC Ltd, the major shareholder in the venture. The company is headquartered at Mumbai.

HDFC ERGO Health Insurance (formerly known as Apollo Munich Health Insurance)
at a Glance

KEY FEATURES HIGHLIGHTS

NETWORK HOSPITALS 10000+

INCURRED CLAIM RATIO 62.47

RENEWABILITY LIFELONG
 WAITING PEROD 3 YEARS

HDFC ERGO Health Insurance Plans (formerly known as Apollo Munich Health
Insurance): Eligibility & Premiums

ADVANTAGES AND BENEFITS OF AVAILING HDFC ERGO HEALTH

INSURANCE PLANS (FORMERLY KNOWN AS APOLLO MUNICH HEALTH
INSURANCE):

HDFC ERGO Health Insurance Limited (formerly known as Apollo Munich Health Insurance Company
Limited) strives to become a trusted leader in the health insurance industry; it provides simple yet innovative
solutions for health insurance. HDFC ERGO Health (formerly known as Apollo Munich) provides a vast
array of health insurance plans that caters to individuals, families, senior citizens, and corporate houses as
well. The company's motto is 'Let’s uncomplicate', which shows its focus on providing effective yet simple
solutions for every healthcare need. It has even been awarded the title of ‘Health Insurance Company of the
year’. Given below are the advantages of

buying health insurance Policies from HDFC ERGO Health (formerly known as Apollo Munich):

• The policyholder can choose from a wide range of sum insured options at affordable premiums, from Rs. 1
Lakh to Rs. 15 Lakh.

• The company has a significant presence all over the country, which offers cashless service to policyholders
at a range of multi-specialty hospitals. The company has specialized doctors who handle and efficiently take
care of the claims throughout. 98% of the claims received by the company are settled within a span of 15
days.

• The HDFC ERGO Health Insurance (formerly known as Apollo Munich Health Insurance Company)
offers the facility of portability if the customer wishes to port their plans from other health insurance
companies to HDFC ERGO Health (formerly known as Apollo Munich Health Insurance). Accumulated
benefits are all integrated and carried forward without any hassles.

• The premiums paid towards a health insurance policy are exempted from tax under section 80D of Income
Tax Act, 1961.

• Expenses incurred both before and after hospitalization are provided to customers.

• Lifelong HDFC ERGO Health Insurance (formerly known as Apollo Munich Health Insurance) renewal
benefit
• If there is a claim-free year, their basic sum insured will be raised by 50% with no extra charge. If the
customer has a second, subsequent no-claim year then their basic sum insured is raised by 100%.

• The policyholder will enjoy a Restore Benefit if the customer or his family member exhausts the sum
insured during the year. The company will restore the full amount whenever a new illness is diagnosed at no
extra paperwork and charges of any sort.

4.27 List of Health Insurance Plans Offered by HDFC ERGO Health (formerly known
as Apollo Munich)

 HDFC ERGO Health wallet plan (formerly known as Apollo Munich health wallet plan)

HDFC ERGO Health wallet plan (formerly known as Apollo Munich health wallet plan) is an individual
health insurance policy that offers coverage to both individuals and family members. This medical plan
covers worldwide emergency care expenses, OPD expenses, daycare procedures, critical illnesses, and
Ayush treatment expenses. Also, there is an option to pay up to 50 percent of the renewal premium without
any co-payment clause. This reserve benefit keeps on increasing year after year. Any unused balance is
carried forward to the upcoming year with a bonus of 6 percent under this benefit.

The Health Wallet Individual Insurance policy by HDFC ERGO Health (formerly known as Apollo Munich
Health) has some add-on benefits such as restore benefit, which reinstate the basic sum assured if the
policyholder exhaust it in the term of the policy and multiplier benefit that rewards him/her for each claim
free year automatically.
 HDFC ERGO Health Optima Restore Plan (formerly known as Apollo Munich
Health Optima Restore Plan:
The HDFC ERGO Health Optima Restore Plan (formerly known as Apollo Munich Health Optima Restore
Plan) is a unique health insurance policy that provides coverage on individual and family floater basis. The
policyholder gets a 100% restoration of the basic sum insured on the first claim during the policy term. The
sum assured is increased by 50% for every claim free year with No-claim-bonus.

Below are some of the features of this medical plan:

 Choice of treatment at any of the network hospitals across the country under cashless facility
 Expenses incurred before and after medication covered for 60 and 90 days, respectively
 Daycare procedures are covered that do not require 24 hours hospitalization
 Domiciliary treatment is covered where the treatment is undertaken at home
 Emergency ambulance charges up to Rs. 2000 are covered
 Expenses incurred for the treatment of the organ donor during transplantation are covered
 A lump sum amount is provided if the person opts to stay in a shared accommodation while being
hospitalized
 Automatic restoration of the basic sum insured if the customers’ basic insured is exhausted during the
course of the year
 There is a facility for E-opinion, which enables the insured to request for a second opinion from
another medical practitioner and the insurer does provide the same.
 There is a Multiplier Benefit in which for every claim-free year, the customer receives a bonus of
50%, accumulating up to 100%.

HDFC ERGO Health Optima Restore Plan Eligibility (formerly known as Apollo
Munich Health Optima Restore Plan Eligibility):

 Insurance coverage is provided from the age of 5 to 65 years.

 Insurance coverage to children is offered right from the fourth month if any of the parents is already
covered
 This HDFC ERGO Health Insurance (formerly known as Apollo Munich Health Insurance) health
Insurance plan has coverage of up to for the self, spouse, dependent children and dependent parents
or parents-in-law

 HDFC ERGO Easy Health Premium Plan (formerly known as Apollo Munich
Easy Health Premium Plan)
 HDFC ERGO Optima Vital Health Insurance Plan (formerly known as Apollo
Munich Optima Vital Health Insurance Plan)

 HDFC ERGO Optima Senior Health Insurance Plan (formerly known as Apollo
Munich Optima Senior Health Insurance Plan)
 HDFC ERGO Optima Plus Health Insurance Plan (formerly known as Apollo
Munich Optima Plus Health Insurance Plan)

 HDFC ERGO Optima Cash Health Insurance Plan (formerly known as Apollo
Munich Optima Cash Health Insurance Plan)
 HDFC ERGO Easy Health Exclusive Insurance Plan (formerly known as Apollo
Munich Easy Health Exclusive Insurance Plan)

 HDFC ERGO Optima Super health Insurance Plan (formerly known as Apollo
Munich Optima Super health Insurance Plan)
  HDFC ERGO Dengue Care Plan (formerly known as Apollo Munich Dengue
Care Plan)

2 Star Health and Allied insurance Co Ltd.

It is India’s first stand-alone health insurance company, dealing in personal accident, mediclaim and travel
insurance Due to its hassle-free and customer-friendly direct claim settlement, the company was bestowed
with "Claims Service Company of the year 2014” award among 28 General Insurance Companies who were
also competing for the same title.

Why Star Health Insurance?

Star Health Insurance offers an array of affordable health insurance policies in order to make them an easy
buy for every individual. The company operates nationwide through over 290 branches while its
policyholders or customers are provided with over 8200 network hospitals. Star Health offers health
insurance in multiple variants along with certain extra benefits, such as:

 India’s first stand-alone health insurance company

  Cashless hospitalization and reimbursement facility in our large network base with more than 8200
hospitals across India
 W.H.O award of excellence 2017 from the former honorable President of India Shri Pranab
Mukherjee
 Best health insurance provider of the year - business today, money today financial awards 2016-2017
 Pan India presence with more than 350 branch offices
 Hassle-free and customer-friendly direct claim settlement without intervention of TPA
 Rated best claim settlement insurer - Hindustan MaRS Survey

2 Future Generali India Insurance Company Ltd

Future Generali is a joint venture between India’s leading retailer Future Group and Italy-based Generali
Group. Catering to divergent needs of life and non-life insurance customers, the company works towards
imparting superior customer service through innovative insurance products and services.

Future Generali Health Plans:

 Future Health Suraksha – Individual: The plan is available for individuals and covers
both pre and post hospitalization expenses, among others. The cover is available to
individuals between the age of 18 and 70 years and come with a lifetime renewal
option. It also allows for covering children aged 3 months to 25 years.
  Future Health Suraksha – Family Floater: The Future Health Suraksha Family Floater policy
covers the entire family for both pre and post hospitalization expenses, patient care costs, day care
procedures, expenses for the accompanying person and ambulance charges. Adults between the ages
of 18 and 70 years can avail the plan. The entry age limit is 55 years for a sum assured of Rs. 10
lakh. People who avail the policy above 55 years can opt for a maximum sum assured of Rs. 5 lakh
 Future Health Surplus: The Health Surplus Plan from Future Generali General Insurance insures
against additional expenses incurred over and beyond a deductible limit. The plan is available on
both individual and family floater basis and has a lifetime renewal option. The policy is available or
adults between the ages of 18 and 65 years.
 Future Criticare: The Future Criticare critical illness cover offers a lump sum benefit provided the
patient survives for more than 28 days from the day of diagnosis and the policy is more than 90 days
old. The policy is available to adults in the 18-65 years age group and has a lifetime renewal option.
The sum insured is Rs. 1-50 lakh for people in the 18-45 years age group and Rs. 1-20 lakh in the 46-
65 years age group.
 Future Hospicash: The Future Hospicash cover allows you to meet any expenses relating to
hospitalization and incidental or related costs. The policy provides benefits for ICU stays both in the
city of residence or outside and additional convalescence benefits for hospital stays of more than 10
days.
 Group Health Insurance (Health Total): A comprehensive retail healthcare plan that is available
on both an individual and family floater basis. Future Generali offers three variants, the Vital plan
that covers the individual, spouse and dependent children, and Superior and Premiere plans that also
cover non-dependent children, dependent or non-dependent parents, grandparents, grandchildren,
dependent siblings, daughter and son in-law, and parents in law.

3 Bajaj Allianz General Insurance Co Ltd

Bajaj Allianz General Insurance Company Limited is a joint venture between Bajaj Finserv Limited
(recently demerged from Bajaj Auto Limited) and Allianz SE. Bajaj Finserv Limited holds 74% and the
remaining 26% is held by Allianz, SE.

 Health Guard Individual Policy: The Health Guard Individual Policy is designed to take care of all
the healthcare needs and offers coverage against medical expenses including hospitalization.
 Health Guard Family Floater Option: The Health Guard Family Floater Option provides perfect
health protection for the entire family against medical expenses including hospitalization, doctor
consultations, diagnostic tests, medicines and ambulance services.
 Premium Personal Guard: The Premium Personal Guard cover is a personal accident insurance
policy that ensures financial security and protection from unforeseen risks and accidents. The
coverage limit is up to Rs. 25 lakh.
 Extra Care: Extra Care is a health insurance policy is a top-up plan that allows you to extend your
existing health insurance coverage up to Rs. 10 lakh at a significantly low cost.
 Critical Illness: The Critical Illness plan as the name suggests is an insurance policy providing cover
against critical illnesses like cancer, tumors and strokes, illnesses that have high treatment costs
 Health Care Supreme: The Health Care Supreme policy is a comprehensive plan that takes care of
medical expenses at every stage of life.
 Hospital Cash Daily Allowance: The Hospital Cash Daily Allowance insurance policy offers a
cover in the event of hospitalization by providing daily cash to help one focus on treatment rather
than managing funds for incidental expenses.
 Bajaj Allianz Personal Accident Insurance: While we cannot do much about the uncertainties of
life, what we can surely do is to secure financial independence to deal with various unforeseen
situations the journey of life throws at us. Bajaj Allianz Personal Accident is a unique insurance plan
that offers multiple benefits such as medical benefits, education benefits to children or spouse and up
to 125% compensation in case of disabilities.
 Bajaj Allianz Extra Care Plus: Medical expenses can take anyone by surprise. With Bajaj Allianz
top-up health insurance plan you can get health insurance cover in addition to your existing health
insurance policy. It can also be purchased as a standalone policy.
 Bajaj Silver Health Insurance Plan for Senior Citizens: This plan is ideal for senior citizens and
people who are between the age group of 46 and 70 years. It also covers pre-existing illnesses from
the 2nd year of the policy term.
 Bajaj Allianz M-Care Health Insurance Plan: In Indian, Vector-borne diseases are on a constant
rise. And this plan is designed to offer you a one-stop solution to offer protection against some of the
most common vector-borne illnesses.

 Bajaj Allianz Global Personal Guard Plan: This plan offers protection to you and your family
against unforeseen medical expenses arising from an accident. The coverage is provided in India as
well as abroad.

 Bajaj Allianz Star Package Health Insurance Plan: This is a family floater plan that offers
coverage to your family against various health risks. It covers household contents, travel baggage,
education grant, and public liability under a single plan.
  Bajaj Allianz Personal Guard: Accident Health Insurance Plan This plan has been designed to
ensure peace of mind and financial security of the family members of the policyholder, in case of his
accidental death or bodily injuries.

 Bajaj Allianz Tax Gain Plan: It is a Family floater health plan that covers hospitalization expenses
along with OPD expenses under a single plan and also helps you in managing taxes.

5 NATIONAL INSURANCE CO Ltd

It is a government-controlled undertaking and provides a wide gamut of insurance products, including

motor, health, personal and fire insurance

The company has a series of cost efficient and health insurance as well as for families which are namely:

 Overseas Mediclaim Business and Holiday Policy

 National Insurance Parivar Mediclaim Policy
 National Insurance Parivar Mediclaim Plus Policy
 Overseas Mediclaim Employment and Studies Policy
 National Insurance Mediclaim Plus Policy
 National Insurance Mediclaim Policy
 National Varistha Mediclaim Policy for Senior Citizen
 National Critical Illness Policy
 National Individual Personal Accident Policy

4 The New India Assurance Co Ltd

Headquartered in Mumbai, The New India Assurance Co. Ltd. is a nationalized general insurance company
operating in 22 nations. Founded in 1919, Indian operations of the country today span across all Indian
territories through 2097 offices.

New India Assurance Health Insurance Plans:

5 The Oriental Insurance Co. Ltd

Incorporated in 1947, Oriental Insurance Co. Ltd. is a pioneer in laying down systems for smooth
functioning of the insurance sector. Headquartered in New Delhi, Oriental Insurance Co. Ltd. has formulated
various insurance products to cater needs of both urban and rural India. It is a central government
undertaking providing general insurance and has operations in Nepal, Kuwait and Dubai.

Oriental Insurance Company Profile

The Oriental Insurance Company Limited laid its foundation stone in Mumbai on September 12, 1947.
Previously, it was wholly owned subsidiary of Oriental Government Security Life Assurance Company
Limited. From 1956 to 1973, the company was a subsidiary of Life Insurance Corporation (LIC) of India
before nationalization of General Insurance Business in India. In 2003, the Union Government acquired all
the shares of Oriental Insurance Company Ltd from General Insurance Corporation of India.

Oriental Insurance Company headquarters located at New Delhi. It has 31 regional offices and more than
1800 active branches across the country. The company has shown its international presence by opening its
branches in Nepal, Kuwait, and Dubai. With more than 14000 employees, Oriental Insurance Company has
emerged as one of the leading general insurance provider in India.
Dr. A K Saxena operates as the Chairman cum Managing Director of Oriental Insurance Company. With a
first-year premium of Rs. 99,556, the company made a modest beginning in 1950. The company has
recorded the Gross Premium of Rs. 7282.54 Crore in the financial year of 2013-2014.

Oriental Health Insurance

plans take care of all your medical emergencies by managing the financial aspect. Once you are sorted
financially, you can concentrate on taking care of the well-being of yourself and your family.

Oriental Individual Mediclaim Insurance Policy

Individual mediclaim policy by Oriental Insurance India is available to any individual between the age of 18
and 80 years for treatment in India. It is a health cover for medical expenses incurred by the insured due to
hospitalisation. The hospitalisation may occur due to a sudden illness, an accident or a surgery necessitated
by a disease, during the policy period

Oriental Family Floater Health Insurance:

The Oriental happy family floater policy by the Oriental Insurance Company Ltd is a health insurance policy
for the entire family including the insured, his or her spouse, children, parents and parents-in-law. The
floater aspect of the policy implies single sum insured for the entire family provided they reside in India. The
policy is available as two plans - Silver and Gold. No medical examination is required for persons up to the
age of 60 years.

Oriental Group Mediclaim Insurance Policy:

This group mediclaim policy from Oriental insurance India is available to any group, association, institution
or a corporate body of more than 50 persons or families, provided it has a central administration point. The
policy reimburses reasonable and necessary expenses for hospitalisation expenses for illnesses or diseases
contracted or injury sustained by the insured persons during the policy period up to the sum insured.

Oriental Jan Arogya Insurance Policy:

The Oriental janarogya policy covers reimbursement of expenses incurred on hospitalisation for any illness,
diseases or injury. In the event of any claim becoming admissible under the scheme, the insured person is
paid an amount equivalent to reasonable expenses that are incurred by or on behalf of the insured person.
However, the amount paid should not exceed the sum insured in any one period of insurance.

Oriental Health of Privileged Elders (HOPE) Insurance Policy:

The Health of Privileged Elders (HOPE) policy has been exclusively designed for citizens aged 60 years and
above. The policy reimburses hospitalisation and/or domiciliary hospitalisation expenses for specified
diseases contracted or injuries sustained by the insured persons. The sum insured amounts available are Rs.
1/2/3/4/5 Lakh.
6 Reliance General Insurance Co Ltd

It is one of the leading private insurance companies in India, with a market share of over 8%. The company
is offering insurance products for motor, health, travel and commercial.

Reliance Health Insurance Plans:

Reliance General Insurance Company is a trusted brand and has proved its worth in all business areas. It has
revolutionized the insurance sector by innovative health Insurance Plans products and exemplary customer
service. When you buy a health plan from Reliance Insurance Company online, you can rest assured that you
are in good hands.

Reliance HealthGain Insurance:

The Reliance HealthGain Policy is perfect health insurance for unseen problems that one might face during
treatment. One can buy the medical insurance policy with a sum insured of Rs. 3 Lakh at any age. Sum
insured options available are Rs. 3/6/9 Lakh. Immediate and extended family members can be covered under
an individual policy. It offers lifelong renewal. Cashless hospitalisation is available in over 4000+ preferred
network hospitals of Reliance Insurance across India.

Reliance Critical Illness Insurance:

The Critical Illness Policy from Reliance Insurance Company covers costs associated with specific critical
illnesses. It has an entry age of 18 to 65 years and lifelong renewability. Medical tests are exempt up to the
age of 45 years. The sum insured options are Rs. 5/7/10/15/20 Lakh.

7 United India Insurance Co Ltd

After the nationalization of the business of United India Insurance Co. Ltd., the company has grown by leaps
and bounds and currently providing insurance coverage to over 1 crore policyholders. The company has
extensive insurance cover to offer from bullock carts to satellites.

Since its inception on 18th February 1938, United India Insurance Company Limited has been offering a
wide range of insurance products to cater to the insurance needs of different segments of society. After the
nationalization of the general insurance business in India, 12 Indian insurance companies, 4 cooperative
insurance societies and Indian operations of 5 foreign insurance companies, besides general insurance
operations of the southern region of LIC were merged with United India Insurance Company Limited. The
Company has its headquarters in Chennai, Tamil Nadu.

Post nationalization, United India Insurance Company has recorded a massive growth both in terms of
revenue and expansion. Currently, it has more than 18,300 employees, spread across 2086 offices, providing
insurance products to more than 1.5 crore policyholders. It is the only company with so much diversification
in its product portfolio that it offers a variety of insurance products to cover products from biogas,
floriculture to satellites United India Insurance Company has been at the forefront in formulating
comprehensive covers for large clients like ONGC Ltd., GMR-Hyderabad International Airport Ltd.,
Mumbai International Airport Ltd., etc. The Company has also played an imperative role in popularizing
insurance in rural areas. It has played a significant role in taking insurance to rural masses with the
implementation of the Universal Health Insurance Program of the Indian Government, Vijaya Raji Janani
Kalyan Yojana, Tsunami Jan Bima Yojana, National Livestock Insurance and many such schemes.

United India Insurance Company Limited - Health Insurance Highlights

Health Insurance Policy - Family Medicare

Family Medicare policy covers all the members of the family under a single sum insured. Family to be
covered can comprise of the insured, spouse and dependent children. The age of the proposer should be
between 18 and 80 years.

Health Insurance Policy - Family Medicare 2014

The Family Medicare 2014 policy covers all the members of the family under a single sum insured. For the
purpose of coverage, the family comprises of the insured, spouse and dependent children. It covers
hospitalization expenses, daycare treatment as well as ayurvedic treatment taken in a government recognized
hospital/ institute.

Individual Health Insurance Policy

The Individual Health Insurance policy covers the insured against any disease contracted or injuries or
illnesses suffered during the policy period that requires hospitalization or medical/surgical treatment. It also
provides domiciliary hospitalization benefits and covers the cost of daycare & AYUSH treatments.
Individuals, families as well as senior citizens can opt for this policy. This policy by United India Insurance
is available in Gold, Platinum and Senior Citizen variants.

Health Insurance Policy - Gold: The entry age for the Gold policy is 36 years to 60 years. People who have
attained 60 years can continue the same policy if they renewed their Gold policies without any gap. The sum
insured under this policy is available between Rs. 1 lakh and Rs. 5 lakh in multiples of Rs. 50,000.
Health Insurance Policy- Platinum: The entry age for the Platinum policy is 18 years to 35 years. The
same policy can be renewed after attaining 35 years if the Platinum policies are renewed without any gap.
The sum insured is available between Rs. 1 lakh and Rs. 10 lakh in multiples of Rs. 50,000.

Senior Citizen Health Insurance Policy: This plan is specially designed for citizens between the ages of 61
years and 80 years. An insured beyond 80 years can continue to be covered under the Senior Citizens policy
provided the policy has been renewed without any break. The sum insured is available between Rs. 1 lakh
and Rs. 3 lakh in multiples of Rs. 50,000.

Super Topup Medicare Policy: The Super Topup Medicare covers hospitalization expenses if the total
expenses cross the threshold level and the amount to be received by any health insurance policy. The sum
insured is available both on individual and floater basis. Various options with different sum insured and
threshold levels are available under this United India Insurance policy.

Top Up Medicare Policy: The Top Up Medicare policy covers hospitalization expenses incurred in India
during the policy period that exceeds the threshold level or any reimbursed or reimbursable amount under
any health insurance policy/reimbursement scheme, whichever is higher, up to the sum insured stated in the
policy. The sum insured under this policy is available on both individual and floater basis.

UNI Criticare Health Plan: The UNI Criticare policy covers 11 critical illnesses and provides lump sum
compensation if the insured is diagnosed with any of these illnesses for the first time during policy term. It
has a waiting period of 90 days from the date of inception of the policy and a survival period of 30 days
from the date of diagnosis. This policy by United India Insurance offers various sum insured options - Rs.
1/3/5/10 lakh.

Workmen Medicare Policy: The Workmen Medicare policy covers hospitalization expenses incurred on
account of an accident to the workmen, during and in the course of employment. The policy has been
designed for contractors, factory owners and commercial establishments who wish to cover their employees
in the event of a workplace accident.

9 Royal Sundaram General Insurance Co. Limited

Royal Sundaram general insurance Co. Limited is the first private general insurance company in India to be
licensed. Since then it has been providing customised insurance solutions to meet the divergent needs of the
individual, family and business. The company offers health, motor, personal accident, home and travel
insurance to individuals. Also, it has a wide range of insurance offerings in marine, fire, engineering, and
liability for commercial clients. Royal Sundaram has specially designed products for small and medium
enterprises and rural customers. is the first private general insurance company in India to be licensed. Since
then it has been providing customised insurance solutions to meet the divergent needs of the individual,
family and business. The company offers health, motor, personal accident, home and travel insurance to
individuals. Also, it has a wide range of insurance offerings in marine, fire, engineering, and liability for
commercial clients. Royal Sundaram has specially designed products for small and medium enterprises and
rural customers.

Currently, Royal Sundaram enjoys the trust of more than 5 million customers. With an employee base of
over 1700, insurance products of the company are distributed across India, through agents, partners and
distribution brokers.

Royal Sundaram's foundations are built on trust, commitment and professionalism. The company is closely
following the ethics of its promoters – Sundaram Finance, one of India’s leading non-banking financial
institutions, and Royal Sundaram General Insurance Co. Limited, the second largest general insurance
company in the UK. These two financial giants have come together to form Royal Sundaram, which is
known in the insurance market for its impeccable global practices, innovative products and personalised
customer service.

Today, Royal Sundaram is a name to reckon with in the insurance market. The company’s accident & health
claims process has got ISO 9001-2008 certification for its high-end customer service delivery. Also, it is the
first insurer to launch cashless modes of settlement and innovative health products like hospital cash in the
market.

Royal Sundaram Health Plans:

Royal Sundaram Lifeline:

The Lifeline Plan is a holistic indemnity cover from Royal Sundaram General Insurance Company Limited
that covers the medical insurance needs of the insured and his/her family. It is available to all individuals
above 18 years of age and is offered as an individual plan as well as a family floater. The family floater
covers the proposer, his/her spouse and children. The cover comes in three variants – Lifeline Classic,
Lifeline Supreme and Lifeline Elite. These plans offer extensive cover starting from Rs. 2 lakh, going up to
Rs. 1.5 crore. All day care procedures are covered under the plan. It also covers AYUSH (Ayurveda, Yoga,
Unani, Siddha and Homoeopathy) treatment as well as vaccination in case of an animal bite. A 100% reload
of sum insured is available at no extra cost. There is no room rent capping or disease specific limits

10 Tata AIG General Insurance Company Limited

Tata AIG General Insurance Company Limited (Tata AIG General) comes into existence after the joint
venture between Tata Group and American International Group, Inc. (AIG). Tata AIG General blends Tata
Group's core values with AIG's global presence as the world's renowned international insurance and
financial services organization. Tata Group holds a 74 percent stake in the insurance venture, while AIG
holds the remaining 26 percent.
Tata AIG Health Insurance Plans:

 Tata AIG Medicare Health Insurance: TATA AIG General Insurance has introduced this plan to
cover Bariatric Surgeries, day care procedures, vaccination cover, accidental death, domiciliary
treatment costs, hospitalization charges, second medical opinion, along with global medical cover
(diagnosed in India).
 Tata AIG MediCare Protect Health Insurance: This plan by TATA AIG General Insurance offers
coverage for in-patient treatment expenses, consumable expenses, organ donor expense, Ayush
treatment cost, ambulance cover, health check-up facility among other benefits.
 Tata AIG MediPrime-Cashless Health Insurance: Tata AIG’s MediPrime is a transparent cashless
health insurance policy without any co-payment on health expenses. It provides comprehensive
hospitalisation coverage without any sub-limits. No medical tests are required on enrolment up to 50
years of age and/or for sum assured up to Rs. 5 lakh. Lifelong renewal is offered provided renewal
premium is paid without any break prior to policy expiry or within the grace period.
 Tata AIG MediCare Premier Health Insurance: TATA AIG General Insurance has designed this
plan to offer special benefits. It includes Emergency Air Ambulance cover, treatment taken outside
India, restore benefits, bariatric surgeries, high-end diagnostics, maternity expenses, first-year
vaccination for the new-born, OPD dental treatment, and compassionate travel costs, apart from
hospitalization expenses.
 Tata AIG Wellsurance Executive Policy: The Wellsurance Executive Policy is designed to take
care of the busy executive and his/her well-being, going beyond what traditional health insurance
policies provide. It can be bought by any individual from 18 years of age up to 65 years. Fixed lump
sum benefit is paid for hospitalisation, post hospitalisation, and critical illnesses. The policy has a
life-long renewability option.
 Tata AIG Wellsurance Family Policy-Family Fixed Benefit Plan: The policy pays special
attention to each family member by caring for their well-being. Fixed lump sum benefit is paid for
hospitalisation and critical illnesses. Children´s education benefit is paid in case of accidental
death/permanent total disability of the policyholder. People between the age of 18 years and 65 years
can purchase the policy. The eligible age for children is 6 months to 18 years (23 years in case
studying for higher education).
 Tata AIG Wellsurance Woman Policy: The AIG General Insurance has designed this health
insurance product to cater to the health requirements/emergencies of today’s modern woman. The
policy looks beyond basic health insurance needs and ensures the total well-being in all phases of
life. Women between the age group of 18 and 65 years can purchase this policy. Fixed lump sum
benefit is paid for 11 critical illnesses. A daily hospital cash benefit, higher hospital cash for
ICU/ICCU admissions, convalescence benefit and cosmetic surgery benefit for accidental injuries is
offered under this policy.
  Tata AIG Critical Illness: The critical illness health insurance policy by Tata AIG General
Insurance is specifically designed to cover a list of 11 critical illnesses. Anyone between the age
group of 18 years and 65 can purchase this insurance policy. The policy provides a lump sum amount
when diagnosed with any of the listed critical illnesses. The second opinion benefit is valid only if
the policy is in force and the insured person has been diagnosed with any of the 11 critical illnesses
covered in the policy.
 Individual Accident and Sickness Hospital Cash Policy: Tata AIG General Insurance’s Individual
Accident and Sickness Hospital Cash is a perfect supplement for an individual’s health insurance
policy and can be taken along with any other health insurance scheme. Anyone between the age
group of 6 months and 65 years can buy the policy. In case of accident and sickness, a daily
hospitalization benefit is paid for up to 180 days. There is no pre-policy check-up required.
 MediPlus-Top-up Medical Health Insurance Plan: The MediPlus cover is a top-up health
insurance plan to enhance one’s current health insurance with a higher total coverage at an affordable
premium. It is the perfect health protection for supplementing one’s primary medical insurance
cover. The policy gives the insured the option to choose between 1 year and 2-year plan option term.
It covers pre, post, and in-patient hospitalisation expenses in addition to expenses related to 140-day
care procedures, domiciliary treatment, organ donor expenses, and emergency ambulance services.
 MediSenior-Senior Citizen Health Insurance Plan: A specially designed health insurance plan by
Tata AIG General Insurance for senior citizens covering all their health-related needs. The minimum
age of entry under this policy is 61 years and above and the policy is issued either for a period of 1
year or 2 years. It covers pre, post, and in-patient hospitalisation expenses. It also covers expenses
related to 140-day care procedures, domiciliary treatment, organ donor expenses, and emergency
ambulance services. The policy offers lifelong renewability option.
 MediRaksha-Affordable Health Insurance Plan: MediRaksha is an affordable health insurance
policy that helps the insured and his/her family in taking care of medical emergencies and rising
medical costs. It is a basic medical insurance plan, covering emergencies and illnesses,
hospitalisation and surgical treatments. No medical tests are required for enrolment up to 55 years of
age. There is no loading on renewal premium in case of a claim.
 Group Accident and Sickness Hospital Cash Policy: Tata AIG General Insurance’s Group
Accident and Sickness Hospital Cash Policy is a perfect supplement to group health insurance
policies and can be taken along with any other health insurance scheme. The entry age ranges from 6
months to 65 years. It provides a daily benefit for accident and sickness hospitalisation. There is no
requirement of pre-policy check-up. Hospitalisation cash up to 180 days is provided in case of
accident or sickness.

11 Bharti AXA General Insurance Co Ltd

It is a joint venture between Bharti Enterprises of India, a pivotal Indian business group and AXA group of
Europe, a world leader in financial protection. Started its operations in 2008, the company currently has 59
branch offices throughout the country. Moreover, it is the first general insurance company to get dual
certifications of ISO 9001:2008 and ISO 27001:2005 within first year of its operations in 2009

Bharti AXA Health Insurance Plans:

When it comes to planning for medical emergencies you tend to worry mainly about the exorbitant hospital
bills. Health care comes with a price tag and arranging for funds during crisis often requires running from
pillar to post, making a dent into your savings or worse. Bharti AXA plans help you to plan for your heath
emergencies so that you can maintain your calm during a medical emergency situation.

 Critical Illness Insurance: The Bharti AXA Critical Illness Insurance policy provides cover for 20
critical illnesses. In the case of diagnosis and survival for 30 days post-diagnosis, a lump sum
compensation is paid equivalent to the sum insured of the plan - Rs. 2, 3 or 5 lakh. This money can
be used as per discretion of the insured. It is easy to get Critical Illness Insurance as no medical
check-up is required up to the age of 45 years.
 Bharti AXA Life Triple Health Insurance Plan: The Bharti AXA Life Triple Health Insurance
Plan is a comprehensive health insurance product that continues to provide protection even after
making a claim. It offers cover for up to three unrelated critical illnesses with premium waiver after
the first claim. The medical cover is provided for 13 critical illnesses, which have been classified into
three groups – Group A, Group B and Group C. One receives 100% of the sum assured for the
remaining two claims as long as the event is not from the same group, subject to a no benefit period
of 365 days between each claim.
 Bharti AXA Life Hospi Cash Benefit Rider: The Bharti AXA Life Hospi Cash Benefit Rider
provides fixed benefit irrespective of the actual expenses incurred each day of hospitalisation. To
avail a claim, the hospitalisation should be for a minimum period of 48 hours while the policy is in
force. It also offers a fixed amount benefit upon admission to an intensive care unit or lump sum
benefit in case of surgery.

12 SBI General Insurance Company Ltd

SBI General Insurance Company Limited is a joint venture between State Bank of India and Insurance
Australia Group (IAG). SBI owns 74% of the total capital and IAG the remaining 26%. SBI General follows
a viable multi-distribution model, encompassing broking & retail direct channels, agency and bancassurance.
Currently, SBI General’s distribution family includes more than 10,000 IRDA certified SBI & associate
bank employees and over 4800 agents. At present, SBI General Insurance Company covers travel, health,
motor, personal accident and home insurance for individuals and group personal accident, group health,
marine package, construction & engineering for businesses
SBI General Health Insurance Policy - Retail:

SBI General Insurance has designed this policy to cover a wide range of medical treatment expenses and
give a sense of security in these times of high healthcare costs. It offers individual as well as family floater
options. The family floater benefits the insured by giving comprehensive protection to one’s family members
under a single policy. This policy by SBI General Insurance is available in flexible plan options including
Metro Plan, Semi Metro Plan and Rest of India. The range of coverage is wide, starting from Rs. 50,000 to
Rs. 5 lakh. People with no medical history do not require any medical tests up to the age of 45.

SBI General Critical Illness Insurance Policy:

Critical Illness Insurance policy by SBI General Insurance provides protection against 13 major critical
illnesses. It helps the insured person to be in control of his finances in times of serious illness. The policy
provides a fixed sum, irrespective of the actual medical expenses incurred. It helps the insured bear the high
cost of treatment associated with critical illness and stay financially stable. This policy by SBI General
Insurance is available in 1-year and 3-year policy tenure options. The sum insured available is up to Rs. 50
lakh and the maximum age of entry is 65 years.

SBI General Hospital Daily Cash Insurance Policy:

The Daily Cash Insurance Policy by SBI General Insurance provides the insured with a fixed benefit for
each day of hospitalization irrespective of the actual medical cost in the event of illness, disease and
accidental bodily injury. It provides additional protection and takes care of additional expenses like
traveling, food, etc. which are not covered under the health insurance policy. This policy by SBI General
Insurance covers ICU hospitalization and accident hospital confinement expenses up to twice the daily
benefit. Flexible plan options are available with a maximum of 30 days and 60 days coverage.

SBI General Arogya Premier Policy:

The Arogya Premier Policy by SBI General Insurance is exclusively designed to meet special healthcare
requirements of high net-worth individuals (HNIs). The plan provides a wider medical coverage option and
allows HNIs to avail the best medical treatment from top medical experts. The policy offers wide coverage
ranging from Rs. 10 lakh to Rs. 30 lakh. It comes with automatic reinstatement of sum insured at no
additional premium cost. Maternity expenses are covered after the completion of first 9 months. Alternative
treatments like Ayurveda, Unani, Siddha and Homeopathy are also covered under this plan by SBI General
Insurance.

SBI General Arogya Plus Policy:

The Arogya Plus Policy is a financial protection against rising OPD medical expenses and hospitalization
expenses. It allows one to focus on treatment by taking care of medical expenses in a better way. There are
multiple coverage options including individual as well as the family floater. Sum insured options are
available in Rs. 1 lakh, 2 lakh and 3 lakh. People with no medical history do not have to undergo any pre-
policy medical tests up to the age of 55 years. The plan by SBI General Insurance covers daycare expenses
of up to 142-daycare procedures.

SBI General Arogya Top Up Policy:

The Arogya Top Up Policy allows the insured to add extra protection at a low premium and smoothly
overcome rising medical costs. It acts as a supplement to the normal health insurance policy. The plan offers
a wide coverage ranging from Rs. 1 lakh up to Rs. 50 lakh with the deductible option of Rs. 1 lakh to Rs. 10
lakh. People with no medical history do not require pre-policy medical tests up to the age of 55 years. Like
the Arogya Plus Policy, the Top Up plan covers daycare expenses for 142-daycare procedures. Alternative
treatment under AYUSH (Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homoeopathy) is also
covered. The policy by SBI General Insurance also covers organ donor expenses. The sum insured can be
reinstated on payment of additional premium.

SBI General Loan Insurance Policy:

The Loan Insurance Policy ensures that the insured is able to pay off the loan taken to build or purchase a
home at times of illness. This unique policy by SBI General Insurance offers covers that include critical
illness, personal accident and loss of employment to take care of possibilities that may hamper in repayment
of the loan. The sum insured is available on a fixed or a reducing balance basis. No medical check-up is
required up to sum insured amount of Rs. 1 crore and/or up to 45 years of age. The policy provides coverage
for 13 critical illnesses, accidental death or permanent disablement, and loss of a job

13 MAX Bupa Health Insurance Company Ltd

MAX Bupa Health Insurance Company is formed after a joint venture between Max India Limited and UK
based Bupa Finance PLC, UK. The perfect combination of both global expertise and local knowledge in
healthcare and insurance makes MAX Bupa the right choice when it comes to safeguarding the health of
your family.

Max Bupa Health Insurance at a Glance:

List of Max Bupa Health Insurance Policies

The Max India Company offers both online plans to customers.

 Health Companion Individual

 Health Companion Family Floater Policy
 Heartbeat - Family First Insurance Policy
 Heartbeat - Family Floater Insurance Policy
 Heartbeat Insurance Policy for Individual
 Health Companion Family First
 Hospital Cash - Health Assurance Insurance Policy
 Critical Illness - Health Assurance Insurance Policy
 Personal Accident - Health Assurance Insurance Policy

14 Cholamandalam MS General Insurance Co Ltd

Chola MS Health Insurance Plans:

Hospitalization expenses can burn a hole in our pocket and alter the quality of life by imposing financial
restrictions. Cholamandalam plans ensure that we can take proper care of ourselves and our family during a
medical emergency. They cover an individual against hospitalisation expenses with option of including
spouse, dependent children and dependent parents with a family discount.

Chola Healthline: The Chola Healthline plan is a comprehensive policy that protects both individuals and
families on a floater sum insured basis. As the primary insured party, you can include your parents, spouse
and dependent children in the family plan. If you apply for individual cover, you can include your siblings
and your in-laws also.
Chola Swasth Parivar Plan: A comprehensive policy that provides cover for hospitalisation expenses
incurred by a family on a floating sum insured basis in addition to personal accident cover that works on an
individual sum insured basis.

Chola Tax Plus Healthline Plan: The Tax Plus Healthline Plan from Cholamandalam offers insurance
against both hospitalisation expenses as well as outpatient or OPD expenses. The policy is available for both
individuals and families on a floater sum basis with the sum insured option ranging from Rs. 1-5 lakh.

Chola Family Healthline Plan: The Family Healthline Insurance floater policy from Chola MS covers both
Allopathy and Ayurvedic treatments. A single policy can cover your spouse and children and allows any
insured member to claim up to the full sum insured. The policy offers a floater sum insured of up to Rs. 15
lakh.

Chola Individual Healthline Plan: The Individual Healthline Insurance policy covers hospitalisation as
well as related expenses. It also covers expense related to pregnancy and for external healthcare aids such as
spectacles or contact lenses, and hearing aids. The policy additionally insures general and eye check-ups
once every two years. The sum insured is up to Rs. 10 lakh per person

Chola MS Top Up Healthline Plan: The policy offers cover for additional medical expenses for both
individuals and families on a floater sum basis. Chola MS offers seven plans with various options for sum
insured or deductibles. Moreover, the policy can be purchased for periods ranging from 1-3 years. No
medical check-ups are necessary up to 55 years of age.

Chola MS Critical Healthline Plan: The Critical Healthline Plan is a fixed benefit policy for critical
illnesses that guards against loss of income or regular living expenses. It offers a flexible sum assured
amount and is also valid for income tax exemption up to Rs. 25,000 per annum under section 80D of the
Income Tax Act

Chola MS Hospital Cash Healthline Plan: The Chola Hospital Cash Healthline plan pays a fixed daily
allowance for every 24 hours spent in the hospital. The payout helps you to take care of miscellaneous
expenses arising during the hospital stay. A lump sum amount is also paid for the period of recovery if
hospitalisation exceeds 20 days on a continual basis.
 CHAPTER 5: CONCLUSIONS AND SUGGESTIONS

5.1 Conclusion:

This paper makes an attempt to understand the awareness, preference and consumption pattern of Health
insurance plan. The result of this study shows that the annual premium is the most important factor that
influences the decision or choice of health Insurance plan. This means that households having higher
income have higher probability of buying healthcare plan. Thus, less income groups may not opt for health
insurance plan. Thus there is a need to develop more products that cater to need of larger and all levels of
income groups. Apart from annual premium, hospital network and disease coverage or coverage of services
hold importance in making choice of healthcare plan. Thus, insurance company should provide larger
network of hospitals and services in their plans in order to satisfy their customer fully. Accessibility of
service provider and company reputation also moderately influence the decisions. The decision made for
choosing the plan is mainly influenced by self-perceptions. Family and relatives and past experience hold
second position for assisting in the choice of plan. Most people would prefer to buy healthcare plan from
private insurance companies for they provide better services and innovative products. Thus, there is large
scope for private insurance companies to grow. The legal and regulatory framework of private health
insurance, particularly because it operates in the voluntary market, should continually balance competing
goals of access, affordability and quality of healthcare and provide health coverage to a larger fraction of the
population with varying risk characteristics and ability to pay. Regulations, aside from their aim of providing
protection of health insurance policyholders and beneficiaries, can be potent tools to promote access to
healthcare, control pricing of health coverage vis-àvis healthcare providers and enhance quality of
healthcare. Allowing the participation of other entities that provide health coverage, such as Hospital and/or
Professional entities, and self-insured health insurance schemes of Mutual Benefit Associations and
Cooperatives would further increase the reach and depth of private health insurance. Licensing standards for
compliance which are enforced on health care provider facilities as well as self-regulation in the medical
profession and within provider groups are necessary for continuing improvement of healthcare quality.
Private health insurance cannot grow if reasonable consumer expectations relating to access, cost and quality
of healthcare remain promises rather than realities. The analysis clearly shows that there is demand for cash
less health insurance scheme but the customers want reduction in number of exclusions and inclusion of pre-
existing diseases. They want the TPAs to be efficient and perform up to the expectation of the policyholders
and insurers. Even though the insurers are providing need based plans but more should be done to meet the
needs arising out of changing lifestyles of people. The population of elderly people, in India, is rising and
they would require institutional care, which is totally missing. The plans need to include pregnancy related
expenses, inclusion of chronic and debilitating diseases, HIV and AIDS, TPAs need to be more efficient in
claims processing and providing better networking for the policyholders. These challenges can be overcome
by setting up and standalone health insurance companies that are run on-profit objective. In most of the
countries life insurance companies underwrite health insurance. In India, life insurers should be allowed to
underwrite health insurance. The tax benefits available at present should be hiked and continued with. The
health plans should be wide based in order to include outpatient care along with in-patient. To create the
awareness of health insurance is very important, the Government and all the associated bodies should all
offer their support in spreading health insurance awareness so that Indian citizens are aware of the right to
seek quality healthcare without any financial thought. and it will help to increase the awareness of health
Insurance among the people

5.2 Suggestions:

 Abolition of the service tax on health insurance products. It has also been

suggested that income tax holidays be accorded to the health insurance

companies for 10 years from the date of incorporation.

 Introduction of a common pool for terminally ill people/people who do not

have access to any kind of health insurance.

 Fraudulent claims, when discovered and proved, should be treated as

criminal offence and subject to strict legal action including imprisonment.

 Systems of co-payment, co-insurance and voluntary deductibles to be used to

(1) Make health insurance more viable,

(2) Control frauds

(3) Refrain customers wanting to avail luxury facilities.

 CHAPTER 6

QUESTIONAIRE

1 Name

2 Place

3 Gender

 Male
 Female
 Other

4 Age

 0-18
 19-30
 30-50
 50-above
 5 marital status
 Single
 Married
 Separated
 Divorced
 Widowed
 Prefer not say

6 type of family

 Joint
 Nuclear
7. Education

 Illiterate
 Primary
 Middle
 Matric
 Higher secondary
 Graduation
 Undergraduate
 Post graduate

8. Occupation

 Full-time employment
 Part-time employment
 Unemployed
 Self-employed
 Home-maker
 Student
 Retired
 Military

9. Income per annum

 Less than 50,000

 50,000-1,00,000
 1,00,000-1,50,000
 1,50,000-2,00,000
 Above 2,00,000

10. Do you know about health insurance

 Yes
 No
11.If yes what are the sources of information

 Tv
 Newspaper
 Agents
 Family
 Friends
 Movies
 Employees of insurance companies
 Tax consultant and doctors
 Others

12. do you have health insurance

 Yes
 No

13. who is your insurer

 Public company
 Private company

14.what type of health insurance policy you have

 Individual health insurance

 Group health insurance
 Family floater health insurance

15. what are the reason going in for health insurance

 Tax planning measures

 Travelling abroad
 Employers contribution
 Existing illness
 Avail good quality medical treatment
 Risk coverage against future illness, old age
16. who persuaded you to purchase the policy

 Insurance officials
 Relatives
 Friends
 Advertisement
 Income tax advocate
 Colleagues
 Yourself

17. what approach was adopted in seeking health insurance coverage

 Insurance agent seeked you out

 You seeked out insurance agent

18. do you agree that the services provided by the insurance companies are delivered effectively

 Yes
 No

19. what is the chances of renewing the services after the expiry of present health insurance plan

 100%
 50%
 25%
 0%

20. are you willing to pay more for additional services, which can be included in your health insurance plan

 Yes
 No

21. do you think the promotional efforts being taken by insurance company are sufficient

 Yes
 No
22. how the awareness of health insurance can be increased

 Newspapers
 Conference and seminars
 Incentives to policy holders
 Renewal notice by insurance companies
 Advertisement
 Sponsoring event by insurance companies
 Internet
 Roadshow, fare & festival
 Introducing saving linked insurance
 Making health insurance mandatory

23.have you ever logged claim with the insurance company

 Yes
 No

24. do you know what are the documents and conditions required for claiming

 Yes
 No

25. which insurance company do you prefer

 Public
 Private
 Other

26. which type of health insurance policy do you prefer

 Individual health insurance

 Family health insurance
 Family floater health insurance
27. at what age do you ideally prefer to get selves and family insured

 0.25
 25-35
 35-45
 45-55
 55-65
 Above 65

28. how do you like to pay health insurance premium amount

 Half monthly
 Monthly
 Quarterly
 Half yearly
 Yearly

29. in what method you would like to pay insurance premium

 Cash
 Cheque
 Online

30.which of the following factors did you consider being the most important while choosing your insurance
policy

 Name and reputation of company

 Capability and knowledge of employees, brokers and corporate agents
 Maximum customers satisfaction
 Prompt claim processing with least of formalities
 Cash less facility
 Minimum co-payment involved
 Availability of tax benefits
 CHAPTER 7

Bibliography

 H. Sadhak (2009), Health Insurance Care In India, sage publication, Delhi

 insurance Regulatory and development Authority (IRDA)
 Dholkia R. Economic reforms: Implications for Health Insurance.

Webliography

www.google.com

www.mediindia.net

www.healthinsuranceindia.org

www.timesofindia.com

www.policybazaar.com/health-insurance/general-info/articles/health-insurance-companies-in-india