PRESENTED BY

JAYSHREE DAS MAYURI KOTHARI MOHD. AFZAL SUNIL GARG KUMAR ANUBHAV

HISTORY
Mediclaim was introduced in 1986, by GIC & covers individual as well as family from age of 5-80 years IRDA introduced in 1999 & allowed private company to set up operations in India

Market Size & Forecasts

Only 2% of Indian population is covered under health insurance. Health insurance is the fastest growing sector in non life insurance sector.

TYPES OF HEALTH INSURANCE POLICIES (COVERAGE)

Family Floater health insurance & Mediclaim Health insurance & Mediclaim for Individuals Health insurance & Mediclaim for Senior Citizens Overseas travel Insurance

Insurance Firms in India 23 firms in India (non life insurer)

LIFE INSURANCE FIRMS IN HEALTH INSURANCE

23 firms (Major Ones are): AVIVA life Insurance Bajaj Allianz Bharti AXA ICICI Prudential LIC Max New York MetLife India

TYPE OF HEALTH INSURANCE POLICY (BENEFITS)

Fixed Benefit Policy: insured can make a claim even if he has already done so under policy from a non-life insurer. Therefore, the lump sum can be used to replace income lost during the period of treatment and recovery. Reimbursement Policy: offer to reimburse the actual expenses incurred by the policyholder in the event of hospitalization. Critical illness plan: amount is paid upon the diagnosis of the disease and not after hospitalization, providing a cushion if the need arises for meeting resultant expenses as well as lifestyle modifications costs. The end-use of the lump sum is not tied to illness, giving insured the freedom to spend it the way he choose.

IMPORTANT EXCLUSION CLAUSES

Pre-Existing Illnesses If insured has undergone treatment for an ailment within 48 months before the policy was issued, the illness will not be covered Waiting Period Pre-existing illnesses will be covered only after a waiting period of 1-4 years No-Claim Period Claims other than those related to accidents cannot be made during the first 30 days of the health policy Sub-Limits Caps are placed by insurers on hospital room rent, surgeons charges, admissible claims on specific diseases, even if the total claim does not exhaust the limit Co-Payment Its the share of eligible claim (10-25 %) that a policyholder agrees to pay. The higher insured contribution, the lower will be the premium

IMPORTANT EXCLUSION CLAUSES

Renewal Policy renewal requests cannot be turned down because of an earlier claim. Reasonability If hospital has charged,say,1 lakh for a treatment, which costs 50,000 elsewhere, claim payout will be restricted to the lower amount

Exclusions Certain events or conditions wont be covered in the first year. For instance, suicide by the insured in the first year of a life insurance policy or piles/cataract in the first year of the health cover
Indisputability Policyholders statements cannot be called into question after two years of issuing the policy

DIFFERENCE BETWEEN HEALTH INSURANCE OPTIONS OF GENERAL INSURER & LIFE INSURER
Life Insurer Mostly new entrant Premiums are fixed for 3-5 years depending on Policy & company Reimbursement cover is like general insurance, fixed benefits ones hands out a pre defined sum If the fixed benefit exceeds the expenditure the balance is returned to the insured General Insurer Old players with long work ex Premiums can go up after every year

Reimburse only actual expenses occurred

No such option

Premiums are higher

Generally lower (1.7% for Bajaj Allainz, Indi. Health Guard)

WHAT HEALTH INSURANCE POLICIES COVERS IN INDIA Illness Accident Surgical requirement Symptoms, when diagnosis is been done according to the document of Cholamandlam MS general Insurance

COSTS COVERED

Pre hospitalization expenses (lab, X ray or all other diagnostic 60 days prior) Hospitalization expenses (Diagnosis, Drugs, Procedures, cost of artificial limb & other equipments) Post hospitalization expenses (max 90 days after discharge)

Also available on Extra premium:

General health & eye examination Local ambulance services Hospital daily allowance

COSTS NOT COVERED

Treatment of illness at home i.e. without hospitalization (oriental Insurance now pays) Pre existing diseases & circumcision Some diseases in first year (cataract, anal fistula etc.) Injuries or diseases attributable to war, invasion, act of foreign enemy, war like operations, nuclear weapons/material Cost of Specs., contact lens, Hearing Aids Dental treatment or Surgery Convalescence, general debility Tonics & vitamins (unless prescribed) Pregnancy, caesarean section, MTP Charges of diagnosis not leading to confirmation of

disease

COOLING OFF PERIOD

1st 30 days any hospitalization is not covered except Accident cases Not applied in case of renewal If breaks occurs in renewal then it applies

CO PAY CONCEPT
Insured has to bear 10% of the admissible claims If insured opt for 20% payment than 10% of relaxation in premium allowed Insured has to bear 10% extra of all the admissible claims for the claims arising out of pre-existing disease for which extra premium is paid

Pre Hospitalization

Hospitalization

Post Hospitalization

Days Covered Apollo Munich (Medi Classic Individual) Royal Sundaram Star Health (Easy Health Individual) 30 30 30- 60 (in case inform 5 days before Hospitalization) All Except room which is 500Rs. Max. upto 3000 in network hospitals Premium All except room which is 2% of SI max. upto 4000 7% of SI max. upto 5000 60 60-90 (with same condition as pre)

Apollo Munich (5 month to 35 years) Royal Sundaram (26-40 Years) 1 year premium Star Health

1.5% (50k)-0.98% (500K) in multiple of 50K 1.8% (100K)-1.37%(500K) in multiple of 50K 1.20% (100K)- 1.21% (500K) in multiple of 100K Max Age Covered

Apollo Munich (5 month to 35 years) Royal Sundaram Star Health

Not Available 50 years (whole family is also covered) Not Available Exclusion of Pre existing Diseases

Apollo Munich (5 month to 35 years) Royal Sundaram

Not Available After 4 years

Special Features (Medi Classic Individual) No Claim Discount ranging from 5% to 25% for every claim free year of insurance (other than Family Package) Discount for voluntary deductibles ranging from 2% to 12% (other than Family Package) 24 X 7 toll-free call centre. Cashless hospitalization in over 3200 network hospitals. Star Health (Easy Health Individual) Cover ambulance services if ambulance service is used on the way to hospital for hospitalization (up to Rs. 2000). A comprehensive health check-up involving a number of medical tests at the end of a block of 4 continuous claim-free years. Covers expenses involved in getting a treatment done at home which otherwise would need hospitalization. Royal Sundaram (Health Shield Online) Ambulance referral facilities Reimbursement of Health check up cost up to Rs.750 per insured person after 5 claim free years of insurance Lump sum payment of 2% of Sum Insured if hospitalization exceeds 15 consecutive days and where liability is admitted for hospitalization Room, Boarding Expenses as charged by the Hospital/Nursing Home subject to a limit of 1.5% and for Intensive Care Unit 3% of the Sum Insured per day.

Pre Hospitalization

Hospitalization

Post Hospitalization

Premium Bajaj Allianz 1.7% (100K) to 1.09% (1000K)

ICICI Pru
TATA AIG

1.98%(100K)
1.11% Max. age covered

Bajaj Allianz ICICI Pru TATA AIG

Up to 55 then up to 85 65

Pre existing Diseases Bajaj Allianz ICICI Pru TATA AIG After 4 years Covered (notified ones)