Fundamentals of Health Insurance PDF

FUNDAMENTALS OF HEALTH INSURANCE DR. SUNIL SADANANDAN SUBJECT MATTER EXPERT [email protected] Recommended for POST GRADUATE DIPLOMA IN HOSPITAL ADMINISTRATION. THE SCOPE OF MEDICAL INSURANCE IN INDIAN SCENARIO INTRODUCTION TO INSURANCE...

FUNDAMENTALS OF HEALTH INSURANCE DR. SUNIL SADANANDAN SUBJECT MATTER EXPERT [email protected] Recommended for POST GRADUATE DIPLOMA IN HOSPITAL ADMINISTRATION. THE SCOPE OF MEDICAL INSURANCE IN INDIAN SCENARIO INTRODUCTION TO INSURANCE : Insurance is a contract/ Legal agreement between two parties – the Insurer and the Insured. An individual or entity, pays a specific amount in advance to an insurance company expecting a guaranteed return– a shield for bearing the risk of loss against specified conditions for self, family, their belongings. The insurance company promises to make good the losses of the insured. The insured receives reimbursement against losses from an insurance company in case of any un- forseen circumstances. HISTORY OF INSURANCE : Modern insurance can be traced back to the city's Great Fire of London, which occurred in 1666. After it destroyed more than 30,000 homes, a man named Nicholas Barbon started a building insurance business. He later introduced the city's first fire insurance company. FIRST INSURANCE COMPANY 1735 The Friendly Society, the first insurance company in the United States, was established in Charleston, South Carolina. This mutual insurance company went out of business in 1740. FATHER OF INSURANCE Solomon Huebner's designation as the “father of insurance education” is undisputed. He taught the first course ever given in insurance, established the insurance department — and became the architect of the modern financial services industry. HISTORY OF INSURANCE IN INDIA Insurance in this current form has its history dating back to 1818, when Oriental Life Insurance Company was started by Anita Bhavsar in Kolkata to cater to the needs of European community. The pre-independence era in India saw discrimination between the lives of foreigners (English) and Indians with higher premiums being charged for the latter. FIRST INSURANCE COMPANY IN INDIA Bombay Mutual Life Assurance Society heralded the birth of first Indian life insurance company in the year 1870, and covered Indian lives at normal rates. REGULATION OF INDIAN INSURANCE COMPANIES At the dawn of the twentieth century, many insurance companies were founded. In the year 1912, the Life Insurance Companies Act and the Provident Fund Act were passed to regulate the insurance business. The industry consisted of only two state insurers: Life Insurers (Life Insurance Corporation of India, LIC) and General Insurers (General Insurance Corporation of India, GIC). GIC had four subsidiary companies. In 1972 with the General Insurance Business (Nationalisation) Act was passed by the Indian Parliament, and consequently, General Insurance business was nationalized with effect from 1 January 1973. 107 insurers were amalgamated and grouped into four companies, namely : National Insurance Company Ltd The New India Assurance Company Ltd., The Oriental Insurance Company Ltd The United India Insurance Company Ltd. 5 MAJOR TYPES OF INSURANCE. 1. Life Insurance 2. Health Insurance 3. Fire Insurance 4. Marine Insurance 5. Vehicle Insurance GOVERNMENT NON-PROFIT SECTOR INSURANCE 1. Ayushman Bharat Yojana: 2. Pradhan Mantri Suraksha Bima Yojana: 3. Aam Aadmi Bima Yojana (AABY): 4. Central Government Health Scheme (CGHS): 5. Employment State Insurance Scheme: 6. Janshree Bima Yojana: 7. Chief Minister’s Comprehensive Ins Scheme: 8. Universal Health Insurance Scheme (UHIS): 9. West Bengal Health Scheme: 10. Yeshasvini Health Insurance Scheme: 11. Mahatma Jyotiba Phule Jan Arogya Yojana 12. Mukhyamantri Amrutam Yojana 13. Karunya Health Scheme: 14. Telangana State Government Employees and Journalists Health Scheme: 15. Dr YSR Aarogyasri Health Care Trust: 16. Pradhan Mantri Fasal Bima Yojana 17. Weather Based Crop Insurance 18. MEDISEP : MEDICAL INSURANCE FOR STATE EMPLOYEES AND PENSIONERS  GOVERNMENT NON-PROFIT SECTOR INSURANCE 1. Ayushman Bharat Yojana: Ayushman Bharat is a universal health insurance scheme of the Ministry of Health and Family Welfare, Government of India. PMJAY was launched to provide free healthcare services to more than 40% population of the country. The scheme offers a health cover of Rs 5 Lakh. In this scheme, it covers medicines, diagnostic expenses, medical treatment, and pre-hospitalization costs. The poorest families of India can benefit from this healthcare scheme. 2. Pradhan Mantri Suraksha Bima Yojana: Pradhan Mantri Suraksha Bima Yojana aims to provide accident insurance cover to the people of India. People in the age group of 18 years to 70 years who have an account in a bank can avail benefit from this scheme. This policy provides an annual cover of Rs 2 lakh for total disability and death cover and Rs 1 lakh for partial disability. The policy premium gets automatically debited from the policyholder’s bank account. 3. Aam Aadmi Bima Yojana (AABY): This is one of the latest National Health Insurance schemes having been established in the year 2007, October. It basically covers individuals from the age of 18 years-59 years. AABY insurance scheme is tailored for all those citizens living in the upcountry and in the rural areas. It also covers the landless citizens who are tenants living both in urban and rural areas. It also includes giving scholarships to underprivileged children. Basically, the head of the family or the earning member is the one protected by this scheme. The premium of 200 rupees per annum is shared equally by the state and the central government. Upon a natural death, the family is compensated at 30000 rupees. However, upon death caused by a permanent disability, the family is compensated at 75,000 rupees. 4. Central Government Health Scheme (CGHS): This scheme was started in the year 1954 and provides comprehensive health care facilities for central government officials and pensioners residing in cities. This scheme has the following main components: All dispensary related services including domiciliary care. In addition, the beneficiaries of this scheme have the privilege of being hospitalized each and every time they fall ill. On the other hand, whenever you have an X-ray or laboratory examination requirements, they would be provided free under this particular scheme. The most important advantage of this National Health Insurance scheme is that it provides free specialists consultations both at hospital level and dispensaries. 5. Employment State Insurance Scheme: This is a multi dimensional National Health insurance scheme due to the fact that it provides social security as well as socio-economic protection to all workers in India. In addition, it provides the same privileges those who depend on workers protected under this scheme. This insurance scheme commences upon the first day of insurable employment to each and every worker. They are provided with full medical care insurance for themselves and their families as well. On the other hand, those covered under this scheme (which is basically workers) are also entitled to a wide range of cash benefits. They include cash in times of physical distress such as sickness or even when one might become disabled may it be temporal or permanent. In addition, for any woman who would lose the capacity to earn or dependents of persons injured during occupational accidents, they are entitled to a monthly pension commonly referred to as dependents benefits. This scheme is not applicable to each and every person or company. It is only applicable to all permanent factories employing more than ten employees. Recently, the scheme has been extended to various businesses including shops, restaurants, road and motor transports and newspaper entities that employ more than 20 people. 6. Janshree Bima Yojana: Janshree Bima Yojana is designed for individuals in the poor category who are within the age group of 18-59 years. The scheme includes special features like Women SHG Groups and Shiksha Sahyog Yojana. At present there are 45 occupational groups under this scheme. 7. Chief Minister’s Comprehensive Insurance Scheme: Chief Minister’s Comprehensive Insurance Scheme is a Tamil Nadu state government scheme. It was launched in association with the United India Insurance Company Ltd. It is a family floater policy that was designed to provide quality health care services to people. This scheme covers more than a thousand medical procedures. In this policy, you can claim for hospitalization expenses up to Rs 5 lakh. The beneficiary can select from both private and government hospitals under this scheme. Tamil Nadu residents with an annual income of lesser than Rs 75000 per year are eligible to enroll under this scheme. 8. Universal Health Insurance Scheme (UHIS): This type of scheme was implemented to help the families who live below the poverty line. It covers the medical expenses of each and every member of the family. In case of death due to an accident, there is a cover that is provided. The main drivers of the Universal Health Insurance Scheme are basically the four public sector general insurance companies who have been doing this with an aim of improving healthcare to the underprivileged and especially the economically disabled citizen in India. Once a family member is hospitalized, this scheme may facilitate the medical expenses of up to 30,000 rupees. However, when the earning head of the family is admitted to the hospital, the Universal health insurance scheme compensates a total of 50 rupees daily for a maximum of 15 days. We can therefore say that this insurance scheme is designed for families below the poverty line. 9. West Bengal Health Scheme: The Government of West Bengal launched this scheme for its employees in the year 2008. It is also available for the pensioners. This coverage is provided on both individual and family floater basis up to a sum insured of Rs 1 lakh. The policy covers OPD treatment and medical surgeries as per the policy terms and conditions. 10. Yeshasvini Health Insurance Scheme: The Karnataka State Government promotes the Yeshasvini Health Insurance Scheme. This scheme is useful for peasants and farmers and who are associated with a co-operative society. This health insurance scheme covers more than 800 medical procedures such as Neurology, Orthopaedic, Angioplasty, etc. Co-operative societies help the farmers to get enrolled in the Yeshasvini Health Insurance Scheme. The beneficiaries can avail of health care services through network hospitals, and coverage benefits are extendible to the beneficiary’s family members. 11. Mahatma Jyotiba Phule Jan Arogya Yojana The Government of Maharashtra introduced this health insurance policy for the benefit of people in the state around. The scheme is going to be helpful for below the poverty line and was targeted at the farmers in Maharashtra. The policy offers a family health cover of up to Rs 1.5 lakh for specified illnesses. The best part about this policy is that there is no waiting period, and it is claimable after the first day itself, unless it is specifically mentioned in the policy terms. 12. Mukhyamantri Amrutam Yojana Mukhyamantri Amrutam Yojana was initiated by the Gujarat government in the year 2012 for the benefit of the poor people living in Gujarat. People who are in the lower middle-income group and below the poverty line are eligible to enroll under the scheme. It is family floater health insurance policy that provides coverage up to Rs 3 lakh per family. The policyholder can avail of medical treatment from private and government hospitals, as well as trust-run hospitals. 13. Karunya Health Scheme: In 2012, the Kerala Government had launched this scheme to provide health cover for listed chronic illnesses. It is a Critical Illness plan for the poor and covers major diseases such as Kidney, Cancer, cardiovascular illnesses, etc. People who are below the poverty line can enroll themselves in this scheme. The beneficiary needs to provide a copy of the Income Certificate and Aadhaar Card for the same. 14. Telangana State Government Employees and Journalists Health Scheme: Telangana Government launched this scheme for its journalists and employees. It is beneficial for the employed, retired, and pensioners. In this scheme, the beneficiary can avail of cashless treatment in the hospitals that are registered. The beneficiaries do not have to rush to arrange funds for emergency medical expenses. 15. Dr YSR Aarogyasri Health Care Trust: Four health welfare schemes were launched by the Andhra Pradesh Government along with the Dr YSR Aarogyasri Trust. These schemes offer medical cover to different people and help them at the time of a medical emergency. The schemes are given below: Dr YSR Aarogyasri scheme for the welfare of the poor Arogya Raksha scheme is for Above the Poverty Line (APL) Working Journalist Health Scheme that provides cashless treatment cover for specified procedures. Employee Health Scheme provides health cover to the state government employees. 16.. Pradhan Mantri Fasal Bima Yojana In April, 2016, the Government of India had launched Pradhan Mantri Fasal Bima Yojana(PMFBY) after rolling back the earlier insurance schemes viz. National Agriculture Insurance Scheme (NAIS), Weather-based Crop Insurance scheme and Modified National Agricultural Insurance Scheme (MNAIS). Thus, at present, PMFBY is the flagship scheme of the government for agricultural insurance in India. 17.. Weather Based Crop Insurance Weather Based Crop Insurance Scheme (WBCIS) aims to mitigate the hardships of the insured farmers against the financial loss owing to the anticipated crop loss resulting from adverse weather conditions relating to rainfall, temperature, wind, humidity etc. WBCIS uses weather parameters as "proxy" for crop yields in compensating the cultivators for the deemed crop losses. Pay out structures are developed to the extent of losses deemed to have been suffered using the weather triggers. 18.. MEDISEP : MEDICAL INSURANCE FOR STATE EMPLOYEES AND PENSIONERS The scheme is intended to provide comprehensive health insurance coverage to all serving employees of the State Government including the High Court of Kerala who are covered under the existing Kerala Government Servants Medical Attendant Rules [KGSMA Rules, 1960] and pensioners. This also includes newly recruited employees and their family, part time contingent employees, part time teachers, teaching, non-teaching staff of aided schools and colleges and their family and pensioners and their spouses and family pensioners on compulsory basis, and all Civil Service officers serving under the Government of Kerala on optional basis. HISTORY OF LIFE INSURANCE Life Insurance in its modern form came to India from England in the year 1818. Oriental Life Insurance Company started by Europeans in Calcutta was the first life insurance company on Indian Soil. The Government of India issued an Ordinance on 19 January 1956 nationalising the Life Insurance sector and Life Insurance Corporation came into existence in the same year. The Life Insurance Corporation (LIC) absorbed 154 Indian, 16 non-Indian insurers and also 75 provident societies—245 Indian and foreign insurers in all. HEALTH INSURANCE : Health insurance otherwise known as medical Insurance has to be considered as a mandatory supportive method for protecting self and family against un-expected, un-precedented financial implications of a wide variety of health-related expenses, ranging from those caused by minor illnesses and injuries to critical diseases. Therefore, health insurance serve as a protective financial shield for the insured person, when they face with a major medical expense. THE NECESSITY : Health Insurance compensates very expensive health care treatment Normally Over 70% of these expenses incurred are out of pocket which leads to lot of hardships. According to a survey by NSSO (National Sample Survey Organization), 40% of the people hospitalized have either had to borrow money or sell assets to cover their medical expenses. REGULATORY BODY FOR INSURANCE SECTOR- IRDA/ IRDAI Insurance Regulatory and Development Authority of India or the IRDAI (also referred to as IRDA) is a government body responsible for regulating and developing the insurance industry in India. Founded in 1999, IRDA is headquartered in Hyderabad and is the apex body of insurance providers in India. IRDAI acts as an authoritative body that is tasked with regulating the insurance and reinsurance sectors in India. The IRDAI is an independent and autonomous statutory body. The primary work of the IRDA revolves around the interest of the policyholder. The creation of IRDA has brought revolutionary changes in the Insurance sector. In the last 10 years of its establishment the insurance sector has seen tremendous growth. IRDA – AUTHORITY As per the section 4 of IRDAI Act 1999, Insurance Regulatory and Development Authority of India (IRDAI, which was constituted by an act of parliament) specify the composition of Authority The Authority is a ten member team consisting of : (a) a Chairman; (b) five whole-time members; (c) four part-time members, (all appointed by the Government of India) MAJOR MISSION STATEMENT OF IRDAI To protect the interest of and secure fair treatment to policyholders; To bring about speedy and orderly growth of the insurance sector. To ensure speedy settlement of genuine claims, to prevent insurance frauds and other malpractices and effective grievance redressal machinery. To take action where such standards are inadequate or ineffectively enforced. PUBLIC SECTOR INSURANCE COMPANIES 1. National Insurance Co Ltd 2. New India Assurance Co Ltd 3. Oriental Insurance Co Ltd 4. United Indian Insurance Co Ltd National Insurance Co. Ltd. Celebrating its 106 glorious years, NIC is the oldest insurance company in India (even older than LIC). With a 14.11% market share, National Insurance Co. Ltd. is the third leading player in the health insurance sector and the fastest growing public non-life insurer. With its robust network of 1,340 offices and 15,200 employees, NIC serves over 16 million customers. New India Assurance Co. Ltd. New India is the first wholly Indian owned insurance company in India. With a 17.89% market share, it stands tall as the nation’s leading general insurance company. Bolstered by a network of 1068 offices and 21000 employees, New India has always tried to add an Innovative approach to insurance products. As a health insurer, New India Assurance launched medi- claim policies that cover Ayurvedic / Homeopathic and Unani system of medicine (limited to 25% of the sum insured), a first of its kind initiative. Oriental Insurance Co. Ltd. Incorporated in 1947, Oriental Insurance Company is a general insurance company owned by the Central Government of India. With over 900 offices and 16,000 employees, Oriental Insurance enjoys 11.94% market share and stands tall as the 5th biggest player in the health insurance sector. Its claim settlement ratio is high and so is its Incurred claim ratio (102.83%), reflecting a high level of trust and reliability, customers can put in this brand. United India Insurance Co. Ltd. United India Insurance, set up in 1938, is one of the oldest insurance companies in India. In 1972, as a consequence of nationalization of general insurance, a number of Indian and foreign insurers merged together with United India Insurance. From that point, there was no turning back for the brand. At present with a 15.09% health insurance market share, United India stands only second to the New India Assurance in the health insurance domain. Supported by 1,340 offices and a diligent workforce of 18,300 employees, the company has insured over 10 million people. PRIVATE COMPANIES 1. Future Generali India Insurance Company Ltd 2. Bajaj Allianz General Insurance Co Ltd 3. ICICI Lombard General Insurance Co Ltd  4. Iffco Tokio General Insurance Co Ltd 5. Reliance General Insurance Co Ltd 6. Royal Sundaram Alliance Insurance Co Ltd 7. TATA AIG General Insurance Co Ltd 8. Cholamandalam MS General Insurance Co Ltd 9. HDFC ERGO General Insurance Co Ltd 10. Universal Sompo General Insurance Co Ltd 11. Bharti AXA General Insurance Co Ltd 12. SBI General Insurance Company Ltd 13. Raheja QBE General Insurance Co Ltd 14. L & T General Insurance Co Ltd 15. Magna HDI General Insurance Co Ltd 16. Liberty Videocon General Insurance Future Generali India Insurance Co. Ltd. Future Generali is a joint venture between Future Group, India’s leading business house and Generali Group, Europe’s largest insurance provider. To give you an idea of how gigantic this group is, Generali Group employs 1,00,000 people serving 70 million clients in 68 countries. Future Generali differentiated itself as a brand by introducing the concept of mall assurance channel that is providing total Insurance solutions at shopping malls. Bajaj Allianz General Insurance Co. Ltd. Bajaj Allianz is the joint venture between Bajaj Finserv Limited and Allianz SE. In a short span of time, the brand made its way to the leading health insurers in India. Features like tie-ups with over 3,200 network hospitals and 24X7 call assistance for claims settlement is the proof of their customer oriented approach. Lowest claim rejection ratio among private health insurance companies The only private insurer to make a whopping profit of Rs 100 crore in the last 4 years. ICICI Lombard General Insurance Co. Ltd. ICICI Lombard GIC Ltd. is a joint venture between ICICI Bank Limited, India's second largest bank and Fairfax Financial Holdings Limited, a Canada based multi-billion dollar financial services company. With a 12.04% market share, ICICI Lombard is the fourth largest general insurance company and the largest among private players. It boasts of having one of the highest claim settlement ratios in the health insurance segment. IFFCO Tokio General Insurance Co. Ltd. IFFCO Tokio is a joint venture between IFFCO (Indian Farmers Fertilizer Co-operative) and its associates and Tokio Marine and Nichido Fire Group, the largest listed insurance group in Japan. The brand is known for its customer focused strategies such as speeding up claim settlements and conducting bi- annual customer satisfaction survey. Reliance General Insurance Co. Ltd. Reliance General Insurance is a subsidiary of Reliance Capital, India’s leading financial services company. The company was set up with an objective to make health insurance an easily accessible product in India through a network of hospitals and distribution channels. Reliance is well keeping up with its objectives via 152 offices spread throughout the country and 24x7 customer care center. First ISO 9001:2000 certified insurance company in India. Royal Sundaram Alliance Insurance Co. Ltd. Royal Sundaram Alliance is joint venture between Sundaram Finance, a non-banking financial company and Royal Sun Alliance, one of the largest insurance companies in UK. The company boasts of providing cashless facility in more than 3000 hospitals throughout India. Currently, it has over 1700 employees fulfilling the health insurance needs of over 5 million customers. The company’s high claim settlement ratio is a reflection of its dedication to its customers. First private sector general insurance company in India to be licensed since 2001 First private insurer to introduce innovative health insurance concepts like hospital cash and cashless settlement. TATA AIG General Insurance Co. Ltd. Tata AIG General Insurance is a joint venture between Tata Group and American International Group, an US based global insurance organization. The brand is a perfect blend of Tata Group's leadership position in India and AIG's global insurance leadership. Cholamandalam MS General Insurance Co Ltd Cholamandalam MS General Insurance Company Ltd (Chola MS) is an Indian insurance firm and a joint venture between the Murugappa Group, an Indian conglomerate, and the Mitsui Sumitomo Insurance Group, a Japanese insurance company. HDFC ERGO General Insurance Co. Ltd. HDFC ERGO General Insurance Company Limited is a joint venture between HDFC Limited, India’s premier Housing Finance Institution & ERGO International AG, the primary insurance entity of Munich Re Group. HDFC is renowned for its customer centric approach and its efficient claim settlement. HDFC has one of the highest claim settlement ratios among health insurers (96% CSR in 2011) and has a comparatively shorter claim settlement turnaround time than most of its competitors. Universal Sompo General Insurance Co Ltd Universal Sompo is a Joint venture of Indian Bank, Indian Overseas Bank, Karnataka Bank, Dabur Investments, and Sompo Japan Insurance Inc. Bharti AXA General Insurance Co. Ltd. Bharti AXA is a joint venture between Bharti Enterprises, India’s leading telecom business group and AXA Group, a global leader in insurance. Recently, it has gained huge attention of the market by transforming the way a claim is perceived by the customer. With their new strategy, they have managed to speed up the claim settlement process by assigning a dedicated claim handler to each insured person making a claim. The brand has also come up with an innovative health insurance product ‘Lifestyle Protection Solution’, that promises to take care of not just health expenses but also lifestyle expenses of the insured. SBI General Insurance Co. Ltd. SBI General Insurance Company Limited is a joint venture between the State Bank of India, the largest banking franchise in India and Insurance Australia Group (IAG), an international general insurance group. With a high incurred claim ratio of 122.82% in 2011-12, SBI gained the trust of the customers and is on its way to capture a big chunk of the health insurance market this year. SBI General registered a staggering 481% growth in premium in 2012. Raheja QBE General Insurance Co Ltd Raheja QBE is a joint venture between Rajan Raheja Group and QBE Insurance, Australia’s second largest global insurer. L & T General Insurance Co. Ltd. L&T General Insurance is a wholly owned subsidiary of Larsen & Toubro Limited which was listed as one of the world's top 50 most reputed companies by Forbes in 2009. L&T General Insurance leads all the other health insurance companies in incurred claim ratio. A high ICR (183.40% for the year 2011-12) is a reflection of how dedicated a company is, in paying out the financial cover to its customers at the time of need. Magna HDI General Insurance Co Ltd Magma HDI General Insurance Company Limited was formed with a joint venture between Magma Fincorp Limited and HDI Global SE Germany. Liberty Videocon General Insurance Liberty General Insurance Limited is a private general insurance company headquartered in Mumbai, India. It is a joint venture among US property casualty insurer Liberty Mutual Insurance Group, Indian private investment fund Enam Securities, and Indian industrial conglomerate DP Jindal Group STAND ALONE INSURANCE COMPANIES 1. Apollo Munich Health Insurance Company limited 2. MAX Bupa Health Insurance Company Ltd 3. Religare Health Insurance Co Ltd 4. Star Health and Allied insurance Co Ltd Apollo Munich Health Insurance Co. Ltd. Apollo Munich is a joint venture between Apollo Hospitals Group, Asia’s largest healthcare provider and Munich Health, a global health insurance leader. With such a cogent tie-up, the brand has created quite a buzz in the market. Apollo Munich Health Insurance is one of the four stand-alone health insurance companies in India and purports to offer the fastest claim settlement though its network of 4000 hospitals and 10,000 doctors. The brand is known for its innovative health insurance plans with unique Cashless authorization done within 2 hours of claim intimation. Max Bupa Health Insurance Co. Ltd. Max Bupa is a joint venture between Max India Limited and the UK based Bupa Finance PLC. This diverse partnership has strengthened the brand with the best of both worlds, Max India’s local expertise and Bupa’s global healthcare experience. Religare Health Insurance Co. Ltd. Religare Health Insurance Co. Ltd. is a joint venture between Religare Enterprises Limited, a leading diversified financial services group based out of India, Union Bank of India & Corporation Bank. Further, the brand is backed up by Fortis Hospitals and SRL Diagnostics. Incepted in the year 2012, Religare is the youngest player among health insurers. The brand has made quite a place for itself in the health insurance segment for its efficient claim servicing. Some distinguishing features that make it a league apart from its competitors include availing treatment anywhere in the world, no claim-based loading and no maximum-entry age limit. Star Health and Allied Insurance Co. Ltd. Star Health is India’s first stand alone health insurer. It is a joint venture between Star Health Investments, ICICI Venture, Sequoia Capital, Oman Insurance Company and ETA Ascon Group. Enjoying 11.06% market share, it is the second biggest private health insurer in India (closely following ICICI Lombard). The two distinguishing features of Star Health as a brand are its direct tie-up with a wide network of hospitals and cashless service without TPA intervention. The brand has been a pioneer in introducing innovative insurance products targeting at a niche. Star citizen red carpet is one such health insurance targeted at people aged between 60 and 75. Star cardiac care, their newest offering is also first-of-its-kind initiative pertaining to the health insurance needs of heart patients. Health Insurance : Selecting a suitable medical insurance is difficult yet incredibly important for you to have a sufficient degree of preparedness against any sudden and, in some cases, expected medical expenses. Imagine a scenario wherein you are diagnosed with a serious medical condition that requires consistent treatment, hospitalisation, and/or surgery. Or simply take the example of the spread of COVID-19 in India and imagine the various expenses you may have to look after if diagnosed with a COVID-19 infection In such a situation, you would not want to let your medical bills dig a massive hole in your savings or be faced with a financial crisis to pay said bills, will you? Hence it is pivotal to buy a suitable health insurance plan. This type of general insurance covers the cost of medical care. It pays for or reimburses the amount you pay towards the treatment of any injury or illness. It usually covers: Hospitalisation The treatment of critical illnesses Medical bills prior to or post hospitalisation. Day care procedures like Cataract operations OPTION TO ADD ON BENEFITS The insured can also opt for add-on benefits like: Maternity cover: Your health insurance covers you for the costs related to childbirth. This includes pre-delivery check-ups, hospitalisation during delivery, and post- natal care. Pre-existing diseases cover: Your health insurance takes care of the treatment of diseases you may have before buying the health insurance policy. Accident cover: Your health insurance can pay for the medical treatment of injuries caused due to accidents and mishaps. TPA? TPA is the abbreviation for Third-party Administrator. As the name suggests, it is someone or some organization that is a third party and an administrator. This brings up the question: what is a third-party administrator? The simple answer is; someone who is not the first or the second party in a health insurance contract (not directly involved) and assists in the administrative aspect of the services mentioned in the contract. For example, Health TPA is someone engaged in administering services related to health insurance. TPA in Health Insurance? The scope of health insurance is a lot wider than other general insurance. The concept of Third-party Administrators (TPA) in health insurance. A TPA in health insurance is an entity that is a third party in a health insurance agreement and administers the claim settlement aspect of the contract between a policyholder and the insurer. Family Health Plan Insurance TPA Limited (FHPL), incorporated in the year 1995 and licensed by IRDAI in the year 2002 is today one of the largest and most reputed IRDAI Licensed Third Party Administrator (TPA) in the country. FHPL with its Registered office at Hyderabad has presence in over 55 locations and 25 states Pan- India catering to the needs of Health Insurance benefits administration for : Individual customers. Corporate clientele. State Government sponsored Health schemes. Central Government sponsored Health schemes. FHPL has a strong and highly experienced management team, over 150 qualified medical personnel and expert work force across locations Pan-India. TPA in a better manner can be defined as : TPA is a link between the insurer and the insured in the case of a hospitalization claim. TPA is chosen by the health insurance company.  TPA’s facilitate the claim settlement process by administrating tasks such as dealing with documents and settling hospital bills. TPAs are licensed by the Insurance Regulatory and Development Authority of India (IRDAI). Insurers associate with TPAs for a smooth claim settlement process. One TPA can be associated with several insurers. FHPL FAMILY HEALTH PLAN INSURANCE TPA LIMITED (FHPL) incorporated in the year 1995 and licenced by IRDAI in 2002. Today FHPL is one of the largest and reputed third party administrator (TPA) in the country. TPA – is the link between the insurance company and the policy holder for availing hospitalisation cover and processing claims. MEDICLAIM WITH FHPL INCORPORATING MAJOR INSURANCE COMPANIES : The member is required to submit the following documents in ORIGINAL, depending upon the terms and conditions of their policy, at any of the FHPL offices: Filled in Claim Form  Photo copy of FHPL ID card, Employee ID, Aadhar card, PAN card & CKYC documents, if required Related Prescriptions Final bill with breakup Original cash paid receipt Discharge Summary Investigation Reports PPN A Public Participation Network (PPN) is a network that allows local authorities to connect with community groups around the country. The PPN is the 'go to' for all local authorities who wish to benefit from community and voluntary expertise in their area. Just like linking the Adhar , PAN Card with Bank account. Another example CIBIL - Credit Information Bureau of India Limited to ensure the CIBIL score as a mandatory tool for sanctioning loan to an individual/ firm. CASHLESS CLAIMS To avail the cashless treatment, member has to first check the list of network hospitals, which are either in FHPL’s or in insurer’s network prior to hospitalization. Produce your FHPL Id card at the Network hospital’s Credit billing section, along with a photo id proof like Aadhar card/Voter Id card/ PAN card etc. Produce previous medical records, if any, for easier cashless approval. Hospital initiates the cashless request. FHPL issue authorisation letter to the hospital as per terms and conditions of your policy. Cashless authorization is issued by FHPL upon verification of records and compliance of terms and conditions of the insurance policy. Members are required to sign on the final bill before leaving the hospital, so that they are aware of the amount utilized by them against their hospitalization. REIMBURSMENT CLAIMS Intimation is mandatory within 24 hours of hospitalization in case of treatment being taken in a non-network hospital. For intimation, the member to provide the TPA (FHPL) the details about the treatment being taken and the approximate estimate towards the hospitalization. The member is required to submit the following documents in ORIGINAL, depending upon the terms and conditions of their policy, at any of the FHPL offices: o Filled in Claim Form o Photo copy of FHPL ID card, Employee ID, Aadhar card, PAN card & CKYC documents, if required o Related Prescriptions o Final bill with breakup  o Original cash paid receipt o Discharge Summary o Investigation Reports Claim is processed based on its merits and SMS /E-Mail alerts are sent to members to keep them updated on their claims status. Courtesy : IRDA and other Insurance regulatory authorities. Authentic details are procured from official websites.