MF Project
MF Project
MF Project
MEANING:
Insurance is a policy from a large financial institution
that offers a person, company, or other entity
reimbursement or financial protection against
possible future losses or damages.
• High-deductible PPO
– Catastrophic coverage
– Low premiums but high deductibles
HEALTH INSURANCE
COMPANY’S
• Tata AIG
• HDFC Chubb
• Bajaj Allianz
• ICICI Lombard
• IFFCO Tokio
• Royal Sundaram
• Oriental Insurance
• Cholaman-dalam
• New India Assurance
• United India Insurance
• National Insurance
(eg)
ICICI PRUDENTIAL
Trust us,
your customer will thank you for it!
NGOs / COMMUNITY-
BASED HEALTH INSURANCE
Community based financing schemes are generally
based on three principals community co-operation
and local self reliance and are typically targeted
towards poorer population in the community who
primarily influence the contribution level and
collecting mechanisms as well as the content of the
benefit package, and allocating the schemes. The
premium is pre-paid and usually flat rate.
Such schemes are generally run by trust hospitals or
nongovernmental organizations (NGOs). The benefits
offered are mainly in terms of preventive care,
though ambulatory and in-patient care is also
covered. Such schemes tend to be financed through
patient collection, government grants and donations.
Increasingly in India, CBHI schemes are negotiating
with the for-profit insurers for the purchase of
custom designed group insurance policies.
Cont…
inpatient facilities in government hospitals and
approved private hospitals. The scheme also covers
non allopathic system of medicine. At present there
are 432,000 beneficiaries spread across 22 cities.
This scheme is mainly funded through Central
Government funds, with monthly premiums
ranging from Rs 15 to Rs 150 based on salary scales.
The CGHS has been criticized from the point of view
of quality and accessibility. Subscribers have
complained of high out-of-pocket expenses due to
slow reimbursement and incomplete coverage for
private health care.
OTHER GOVERNMENT
INITIATIVES
COMPARISONS
The Commonwealth Fund, in its annual survey,
"Mirror, Mirror on the Wall", compares the
performance of the health care systems in Australia,
New Zealand, the United Kingdom, Germany,
Canada and the U.S. Its 2007 study found that,
although the U.S. system is the most expensive, it
consistently under-performs compared to the other
countries. One difference between the U.S. and the
other countries in the study is that the U.S. is the
only country without universal health insurance
coverage.
Australia
The public health system is called Medicare. It
ensures free universal access to hospital treatment
and subsidised out-of-hospital medical treatment. It
is funded by a 1.5% tax levy on all taxpayers, an
extra 1% levy on high income earners, as well as
general revenue.
Cont…
Party under Kevin Rudd which had already pledged
that it would remain in government ownership.
Cont…
periods, in particular for pre-existing conditions
(usually referred to within the industry as PEA, which
stands for "pre-existing ailment"). Funds are entitled
to impose a waiting period of up to 12 months on
benefits for any medical condition the signs and
symptoms of which existed during the six months
ending on the day the person first took out
insurance. They are also entitled to impose a 12-
month waiting period for benefits for treatment
relating to an obstetric condition, and a 2-month
waiting period for all other benefits when a person
first takes out private insurance. Funds have the
discretion to reduce or remove such waiting periods
in individual cases. They are also free not to impose
them to begin with, but this would place such a fund
at risk of "adverse selection", attracting a
disproportionate number of members from other
funds, or from the pool of intending members who
might otherwise have joined other funds. It would
also attract people with existing medical conditions,
who might not otherwise have taken out insurance at
all because of the denial of benefits for 12 months
due to the PEA Rule. The benefits paid out for these
conditions would create pressure on premiums for all
the fund's members, causing some to drop their
membership, which would lead to further rises in
premiums, and a vicious cycle of higher premiums-
leaving members would ensue.
Cont…
There are a number of other matters about which
funds are not permitted to discriminate between
members in terms of premiums, benefits or
membership - these include racial origin, religion,
sex, sexual orientation, nature of employment, and
leisure activities. Premiums for a fund's product that
is sold in more than one state can vary from state to
state, but not within the same state.
Cont…
pay a 1% surcharge on top of the standard 1.5%
Medicare Levy. The rationale is that if the people
in this income group are forced to pay more
money one way or another, most would choose to
purchase hospital insurance with it, with the
possibility of a benefit in the event that they need
private hospital treatment - rather than pay it in
the form of extra tax as well as having to meet
their own private hospital costs.
Cont…
Rebate would become means-tested, and offered on
a sliding scale.
Canada
Health care is mainly a constitutional, provincial
government responsibility in Canada (the main
exceptions being federal government responsibility
for services provided to aboriginal peoples covered
by treaties, the Royal Canadian Mounted Police, the
armed forces, and members of parliament).
Consequently each province administers its own
health insurance program. The federal government
influences health insurance by virtue of its fiscal
powers - it transfers cash and tax points to the
provinces to help cover the costs of the universal
health insurance programs. Under the Canada Health
Act, the federal government mandates and enforces
the requirement that all people have free access to
what are termed "medically necessary services,"
defined primarily as care delivered by physicians or
in hospitals, and the nursing component of long term
residential care. If provinces allow doctors or
institutions to charge patients for medically
necessary services, the federal government reduces
its payments to the provinces by the amount of the
prohibited charges. Collectively, the public provincial
health insurance systems in Canada are frequently
referred to as Medicare. This public insurance is tax-
funded out of general government revenues,
Cont…
although British Columbia and Ontario levy a
mandatory premium with flat rates for individuals
and families to generate additional revenues - in
essence a surtax. Private health insurance is allowed,
but in six provincial governments only for services
that the public health plans do not cover, for
example, semi-private or private rooms in hospitals
and prescription drug plans. Four provinces allow
insurance for services also mandated by the Canada
Health Act, but in practice there is no market for it.
All Canadians are free to use private insurance for
elective medical services such as laser vision
correction surgery, cosmetic surgery, and other non-
basic medical procedures. Some 65% of Canadians
have some form of supplementary private health
insurance; many of them receive it through their
employers. Private-sector services not paid for by
the government account for nearly 30 percent of
total health care spending.
Cont…
core issues of supply and demand and the impact of
wait times.
France
The national system of health insurance was
instituted in 1945, just after the end of the Second
World War. It was a compromise between Gaullist
and Communist representatives in the French
parliament. The Conservative Gaullists were opposed
to a state-run healthcare system, while the
Communists were supportive of a complete
nationalisation of health care along a British
Beveridge model.
Cont…
(there are five: General, Independent, Agricultural,
Student, Public Servants) now all reimburse at the
same rate. Secondly, since 2000, the government
now provides health care to those who are not
covered by a mandatory regime (those who have
never worked and who are not students, meaning
the very rich or the very poor). This regime, unlike
the worker-financed ones, is financed via general
taxation and reimburses at a higher rate than the
profession-based system for those who cannot afford
to make up the difference. Finally, to counter the rise
in health-care costs, the government has installed
two plans, (in 2004 and 2006), which require insured
people to declare a referring doctor in order to be
fully reimbursed for specialist visits, and which
installed a mandatory co-pay of 1 € (about $1.45)
for a doctor visit, 0,50 € (about 80 ¢) for each box of
medicine prescribed, and a fee of 16-18 € (20-25 $)
per day for hospital stays and for expensive
procedures.
Cont…
complementary insurance plans available. The
market for these programs is very competitive, and
often subsidised by the employer, which means that
premiums are usually modest. 85% of French people
benefit from complementary private health
insurance.
Netherlands
In 2006, a new system of health insurance came into
force in the Netherlands. This new system avoids the
two pitfalls of adverse selection and moral hazard
associated with traditional forms of health insurance
by using a combination of regulation and an
insurance equalization pool. Moral hazard is avoided
by mandating that insurance companies provide at
least one policy which meets a government set
minimum standard level of coverage, and all adult
residents are obliged by law to purchase this
coverage from an insurance company of their choice.
All insurance companies receive funds from the
equalization pool to help cover the cost of this
government-mandated coverage. This pool is run by
a regulator which collects salary-based contributions
from employers, which make up about 50% of all
health care funding, and funding from the
government to cover people who cannot afford
health care, which makes up an additional 5%.The
remaining 45% of health care funding comes from
insurance premiums paid by the public, for which
Cont…
companies compete on price, though the variation
between the various competing insurers is only
about 5%. However, insurance companies are free to
sell additional policies to provide coverage beyond
the national minimum. These policies do not receive
funding from the equalization pool, but cover
additional treatments, such as dental procedures and
physiotherapy, which are not paid for by the
mandatory policy.
United Kingdom
The UK's National Health Service (NHS) is a publicly
funded healthcare system that provides coverage to
everyone normally resident in the UK. It is not
strictly an insurance system because (a) there are no
premiums collected, (b) costs are not charged at the
patient level and (c) costs are not pre-paid from a
pool. However, it does achieve the main aim of
insurance which is to spread financial risk arising
from ill-health. The costs of running the NHS (est.
£104 billion in 2007-8) are met directly from general
taxation. The NHS provides the majority of health
care in the UK, including primary care, in-patient
care, long-term health care, ophthalmology and
dentistry.
Cont…
ageing, menopause and puberty; AIDS/HIV; allergies
or allergic disorders; birth control, conception, sexual
problems and sex changes; chronic conditions;
complications from excluded or restricted conditions/
treatment; convalescence, rehabilitation and general
nursing care ; cosmetic, reconstructive or weight
loss treatment; deafness; dental/oral treatment
(such as fillings, gum disease, jaw shrinkage, etc);
dialysis; drugs and dressings for out-patient or take-
home use† ; experimental drugs and treatment;
eyesight; HRT and bone densitometry; learning
difficulties, behavioural and developmental
problems; overseas treatment and repatriation;
physical aids and devices; pre-existing or special
conditions; pregnancy and childbirth; screening and
preventive treatment; sleep problems and disorders;
speech disorders; temporary relief of symptoms. (†
= except in exceptional circumstances)
Cont…
Meeting which had been agreed earlier by the
Consultants Policy Group (i.e. Senior physicians)
stating that the BMA was "extremely concerned that
the policies of some private healthcare insurance
companies are preventing or restricting patients
exercising choice about (i) the consultants who treat
them; (ii) the hospital at which they are treated; (iii)
making top up payments to cover any gap between
the funding provided by their insurance company and
the cost of their chosen private treatment." It went
in to "call on the BMA to publicise these concerns so
that patients are fully informed when making choices
about private healthcare insurance." The NHS offers
patients a choice of hospitals and consultants and
does not charge for its services.
United States
The United States health care system relies heavily
on private health insurance, which is the
primary source of coverage for most Americans.
According to
Cont…
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Germany
Germany has Europe's oldest universal health care
system, with origins dating back to Otto von
Bismarck's Social legislation, which included the
Health Insurance Bill of 1883, Accident Insurance Bill
of 1884, and Old Age and Disability Insurance Bill of
1889. As mandatory health insurance, these bills
originally applied only to low-income workers and
certain government employees; their coverage, and
that of subsequent legislation gradually expanded to
cover virtually the entire population.
Cont…
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