Fundamentals of Health Insurance in India

Fundamentals of Health Insurance

• Health insurance is a contract between two parties: the insurer and the insured.
• The insured pays a specific amount to the insurer for a guaranteed return, protecting against loss.
• The insurer promises to cover losses caused by unforeseen circumstances.

Scope of Medical Insurance in India

• Modern insurance originated in the Great Fire of London 1666.
• Nicholas Barbon established the first fire insurance company.

First Insurance Company

• The Friendly Society was the first US insurance company established in 1735 in Charleston, South Carolina.
• Solomon Huebner is recognized as the "father of insurance education".

History of Insurance in India

• Oriental Life Insurance Company, established in 1818, was the first Indian life insurance company that catered to Europeans.
• The pre-independence era in India saw discrimination with higher premiums for Indians.
• Bombay Mutual Life Assurance Society, established in 1870, covered Indian lives at normal rates.

Regulation of Indian Insurance Companies

• The Life Insurance Companies Act and the Provident Fund Act of 1912 regulated insurance business.
• The industry consisted of two state insurers: Life Insurers (LIC) and General Insurers (GIC).
• In 1972, the General Insurance Business (Nationalisation) Act nationalized general insurance with effect from 1 January 1973.

5 Major Types of Insurance

• Life insurance
• Health insurance
• Fire insurance
• Marine insurance
• Vehicle insurance

Government Non-Profit Sector Insurance

• Several government-sponsored insurance schemes exist in India, targeting different categories of people.
• Some examples include schemes for the poor, farmers, employed, and pensioners. Specific schemes mentioned include Ayushman Bharat, Pradhan Mantri Suraksha Bima Yojana, Aam Aadmi Bima Yojana, Central Government Health Scheme, Janshree Bima Yojana, and others.

Regulatory Body for Insurance Sector - IRDA/IRDAI

• IRDAI, the Insurance Regulatory and Development Authority of India, is a government body responsible for regulating and developing the insurance industry in India.
• IRDAI was founded in 1999 and is headquartered in Hyderabad.

Public Sector Insurance Companies

• National Insurance Co. Ltd.
• New India Assurance Co. Ltd.
• Oriental Insurance Co. Ltd.
• United India Insurance Co. Ltd.

Private Companies

• A list of private insurance companies are provided.

TPA

• Third-Party Administrator (TPA) is an intermediary that assists in the claim settlement process in health insurance.
• Family Health Plan Insurance TPA Limited (FHPL) is a notable TPA in India.

Cashless Claims

• Members must provide required documents, including photo ID proof, to initiate cashless claims at approved network hospitals.

Reimbursement Claims

• Members must notify the TPA (FHPL) within 24 hours of hospitalization if it is a non-network claim.