Dr. Daleep Pandita
Getting easily the good quality and affordable healthcare is an important service that every citizen of our country is looking for. Healthy population leads to a developed society which really indicate the progress of a country. At the ground level, lot needs to be done in this direction particularly for rural India. Country’s vast population enveloped with variety of complex health problems throw tedious uphill challenge for the present government to redefine existing healthcare system in order to address this need of the hour and ensure health safety for the future.
Providing health insurance security is one of the important solutions in this direction. Truly health insurance word is not much heard in rural India and with much hic cups in the mindset at urban level. As on date, nearly five percent of our population is covered under various health insurance schemes. This concept has not been percolated adequately down the masses and explained properly among the needy. Prevailing commercialization of existing medical system makes the health insurance service in India more complicated. Inadequate infrastructure of its service providers with non serious approach from the government ultimately render it difficult for a common man to easily avail this facility. Government immediately need to declare this segment under social obligation and encourage public private participation to tape this large virgin portfolio.
Lot of non life general insurance companies including exclusive health insurance providers, both at government and at private level provide health insurance schemes in India. But their presence is mostly felt in urban India leaving much behind unattended the vast innocent uneducated rural population. Further their limited operations are mainly focused on their profitability concept at the cost of their social responsibility.
Although all these service providers are regulated by Insurance Regulatory and Development Authority of India ( IRDA ) but need to be openly controlled by the government and made accountable in order to ensure their vast reach with variety of products available at affordable prices. With this intention, IRDA has recently constituted a high level select committee to find out ways for spreading health insurance portfolio in India. Similarly Government need to redefine its role and share responsibility for providing sufficient availability of complete and quality health care system including medical specialists, specialized hospitals, automatic laboratories and trained paramedical staff to make much needed health insurance programme a grand success at the ground level. Although government is slightly encouraging the option of availing medical insurance facility by granting income tax rebate up to Rs. 20,000 on its premium paid, which has no meaning for the poor who is the most needy for the quality health care. Government must increase in budgetary allocations both at central and state level under health sector specifically for spreading heath insurance schemes among the masses.
Canvassed by the marketing forces, the channels of selling health insurance products in our country comprise agents, brokers, banks, financial institutions and many other authorized inter mediatory representatives. Further, these insurance companies can be also approached by on line methods. Their different products at varied prices can be compared accordingly and availed as per the specific needs suiting to the pockets but subject to in depth study of their coverages and importantly their exclusions.
Medical insurance can be availed by an individual, for a family or to a group through an individual or a floater cover of chosen amount of liability, its sum insured. Traditionally this insurance cover reimburses expenses incurred on treatment of a disease/ illness or injury sustained where minimum of 24 hour hospitalization at registered hospital or nursing home is required. It does not cover any pre existing ailment for the first year and some specific chronic diseases for the first two years of inception of this policy. Some companies also do not cover any loss in first 30 days from the commencement of period of insurance cover, considering it as latent waiting period, excepting due to accidents. Family for health insurance purposes mean, spouse, two eligible dependent children and dependent parents or parent in laws.
The entry age can be from 3 months up to 65 year irrespective of sex, occupation or risk category. Before 3 months of age, infant is covered along with mother and beyond 65 years, only its previous insurance policy can be renewed till the insured wishes to continue with it but in any case can not be granted a fresh cover after 65 years of age. Certainly it is a discouraging draw back for senior citizens when they require health security the most. Normally no medical examination is required up to the age of 45 years after which pre acceptance health check up and basic medical investigations are mandatory requirements imposed by some insurers. Similar medical formalities are also required for enhancement of sum insured of the existing insurance cover. One illness means continuous period of sickness if it does not relapse within 45 days of its occurrence after which it shall be considered a fresh illness. There is provision of changing the type of insurance product or shifting of insurance company, without forfeiting any benefits on previous policy like free health check up earned on consecutive four claim free years.
The premium chargeable on various health insurance products varies with the geographical area depending upon the zones opted for undertaking treatment. Some insurance companies also load the premium in case the pre existing diseases, diabetes, hypertension and many others, if opted are to be covered. There is loading of premium for age above 70 years and for adverse claim experience. Maternity benefits are also covered by paying extra premium. This insurance scheme also provides benefit of family discount of ten percent on premium, per year 5 percent increase in sum insured for each claim free year and reimbursement of cost health check after every 4 claim free years.
In India, the post sale service at the time of claim under health insurance sector is rendered through authorized Third Party Administrator ( TPA ). Cashless facility is provided after its approval by TPA at their designated hospital network including private and specialized hospitals all over India. Medical expenses incurred during 30 days before undergoing hospitalization as Pre hospitalization benefit and 60 days after discharge from hospital as Post hospitalization are payable under most of health insurance polices .
Exclusions under health insurance policy are most important area to be borne in the mind of every existing and future insured. Any false declaration or manipulation at the time of taking this insurance cover render the policy null and void, forfeiting its all benefits and defeating the very purpose. Pre existing diseases and ailments are not covered until declared and accepted to be covered by the insurer. Expenses on tonics, nutritive supplements, vitamins, health additives, general debility, run down condition etc. are not payable unless not forming an essential part of treatment. Expenses on ornamental and cosmetic surgeries, cost of spectacles and contact lenses etc. are also not payable. Expenses arising out of treatment on AIDS are also not payable. Expenses incurred under allopathic system of medicine are payable by all the insurance companies while as treatment under other traditional forms of medicine in India are considered differently for reimbursement by various insurance companies.
With lot of hic cups in existing medical insurance products and inadequate spread of health insurance schemes coupled with weak health care facilities, government really need to seriously rethink on this segment to make the population health secure and the society healthy.
( The author is Divisional Manager General Insurance Company at Jammu )
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