Overview of Health Insurance

Study Notes

Health insurance covers part or all medical expenses, distributing risk among multiple individuals.
Defined as coverage providing payment for benefits resulting from sickness or injury, including losses from accidents, medical costs, and disability.

Ensures affordability of medical treatment for illnesses or accidents.
Offsets costs of various medical services, including doctor bills, surgeries, and pharmaceuticals.

A contract between an insurance provider and individual/sponsor outlining covered healthcare costs.
Specifies coverage details in written form.

Premium: Amount paid by the policy-holder or sponsor to purchase health coverage; determined by factors like age, location, tobacco use, and plan category.
Deductible: Out-of-pocket amount paid by the insured before coverage kicks in.
Co-payment: Fixed amount paid by the insured for specific visits or services before insurance coverage.
Coinsurance: Percentage of total costs shared by the insured after meeting deductibles.
Exclusions: Certain services, like non-essential items, are not covered; insured pays out-of-pocket for these.
Coverage Limits: Maximum amount insurance will pay for services; excess costs are the responsibility of the insured.
Out-of-pocket Maximum: Total payments the insured must make before the insurance covers all further costs.

Fast-paced lifestyle increases health risks.
Common diseases affect children due to changing habits and environmental factors, including pollution.
Mental stress, lack of exercise, and new unexpected diseases further necessitate health coverage.

Factors contributing to increasing costs include specialty healthcare, investigative treatments, hospital infrastructure, medical equipment, inflation, and rising drug prices.

Low consumer awareness and limited product development hinder market growth.
Challenges include pricing pressures and insufficient communication between insurance entities and healthcare providers.
Knowledge gaps among staff and agents affect service delivery and outreach.

Enhances awareness of insurance options among consumers.
Facilitates the selection of suitable health policies and reduces financial strain through the absence of immediate cash requirements.
Streamlines the claim settlement process, reducing stress and complexity.

Sudan allocates approximately 6.5% of its GDP and 8.2% of government expenditure to health.
Approximately 70% of healthcare costs are out-of-pocket, highlighting limited government funding.
Social Health Insurance (SHI) initiated in 1997 aims to improve accessibility to healthcare services.