Report on health insurance 2

8/7/2019 Report on health insurance 2

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HEALTH INSURANCE

IN INDIA

Jaideep Kumar

MPH 2nd Semester


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Contents:

1 .Introduction

2. Public health and Health insurance

3. History and evolution

4. Insurance Acts in India

5. Insurance schemes in India

6. Comparison

o Australiao Canadao Franceo Netherlandso United Kingdomo United States

7. Conclusion

8. Refrences
http://en.wikipedia.org/wiki/Health_insurance#History_and_evolution%23History_and_evolutionhttp://en.wikipedia.org/wiki/Health_insurance#History_and_evolution%23History_and_evolutionhttp://en.wikipedia.org/wiki/Health_insurance#History_and_evolution%23History_and_evolutionhttp://en.wikipedia.org/wiki/Health_insurance#History_and_evolution%23History_and_evolutionhttp://en.wikipedia.org/wiki/Health_insurance#History_and_evolution%23History_and_evolutionhttp://en.wikipedia.org/wiki/Health_insurance#Comparison%23Comparisonhttp://en.wikipedia.org/wiki/Health_insurance#Australia%23Australiahttp://en.wikipedia.org/wiki/Health_insurance#Australia%23Australiahttp://en.wikipedia.org/wiki/Health_insurance#Canada%23Canadahttp://en.wikipedia.org/wiki/Health_insurance#Canada%23Canadahttp://en.wikipedia.org/wiki/Health_insurance#France%23Francehttp://en.wikipedia.org/wiki/Health_insurance#France%23Francehttp://en.wikipedia.org/wiki/Health_insurance#Netherlands%23Netherlandshttp://en.wikipedia.org/wiki/Health_insurance#Netherlands%23Netherlandshttp://en.wikipedia.org/wiki/Health_insurance#United_Kingdom%23United_Kingdomhttp://en.wikipedia.org/wiki/Health_insurance#United_Kingdom%23United_Kingdomhttp://en.wikipedia.org/wiki/Health_insurance#United_States%23United_Stateshttp://en.wikipedia.org/wiki/Health_insurance#United_States%23United_Stateshttp://en.wikipedia.org/wiki/Health_insurance#History_and_evolution%23History_and_evolutionhttp://en.wikipedia.org/wiki/Health_insurance#History_and_evolution%23History_and_evolutionhttp://en.wikipedia.org/wiki/Health_insurance#History_and_evolution%23History_and_evolutionhttp://en.wikipedia.org/wiki/Health_insurance#Comparison%23Comparisonhttp://en.wikipedia.org/wiki/Health_insurance#Australia%23Australiahttp://en.wikipedia.org/wiki/Health_insurance#Canada%23Canadahttp://en.wikipedia.org/wiki/Health_insurance#France%23Francehttp://en.wikipedia.org/wiki/Health_insurance#Netherlands%23Netherlandshttp://en.wikipedia.org/wiki/Health_insurance#United_Kingdom%23United_Kingdomhttp://en.wikipedia.org/wiki/Health_insurance#United_States%23United_States


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1.Introduction:-

Health Insurance

Health insurance in a narrow sense would be an individual or group purchasing health

care coverage in advance by paying a fee called premium. In its broader sense, it wouldbe any arrangement that helps to defer, delay, reduce or altogether avoid payment forhealth care incurred by individuals and households.

How it works:-

A healthinsurance policy is a contract between an insurance company and an individual.The contract can be renewable annually or monthly. The type and amount of health carecosts that will be covered by the health plan are specified in advance, in the membercontract or Evidence of Coverage booklet. The individual policy-holder's paymentobligations may take several forms.

Premium: The amount the policy-holder pays to the health plan each month topurchase health coverage.

Deductible: The amount that the policy-holder must pay out-of-pocket before thehealth plan pays its share. For example, a policy-holder might have to pay a 500/-rupees deductible per year, before any of their health care is covered by thehealth plan. It may take several doctor's visits or prescription refills before thepolicy-holder reaches the deductible and the health plan starts to pay for care.

Copayment: The amount that the policy-holder must pay out of pocket before thehealth plan pays for a particular visit or service. For example, a policy-holdermight pay a 50/-Rs copayment for a doctor's visit, or to obtain a prescription. A

copayment must be paid each time a particular service is obtained. Coinsurance: Instead of paying a fixed amount up front (a copayment), the

policy-holder must pay a percentage of the total cost. For example, the membermight have to pay 20% of the cost of a surgery, while the health plan pays theother 80%. Because there is no upper limit on coinsurance, the policy-holder canend up owing very little, or a significant amount, depending on the actual costs ofthe services they obtain.

Exclusions: Not all services are covered. The policy-holder is generally expectedto pay the full cost of non-covered services out of their own pocket.

Coverage limits: Some health plans only pay for health care up to a certain dollaramount. The policy-holder may be expected to pay any charges in excess of thehealth plan's maximum payment for a specific service. In addition, some planshave annual or lifetime coverage maximums. In these cases, the health plan willstop payment when they reach the benefit maximum and the policy-holder mustpay all remaining costs.

Out-of-pocket maximums: Similar to coverage limits, except that in this case,the member's payment obligation ends when they reach the out-of-pocketmaximum, and the health plan pays all further covered costs. Out-of-pocketmaximums can be limited to a specific benefit category (such as prescription
http://en.wikipedia.org/wiki/Healthhttp://en.wikipedia.org/wiki/Insurancehttp://en.wikipedia.org/wiki/Insurance_contracthttp://en.wikipedia.org/wiki/Deductiblehttp://en.wikipedia.org/wiki/Out-of-pocket_expenseshttp://en.wikipedia.org/wiki/Copaymenthttp://en.wikipedia.org/wiki/Coinsurancehttp://en.wikipedia.org/wiki/Healthhttp://en.wikipedia.org/wiki/Insurancehttp://en.wikipedia.org/wiki/Insurance_contracthttp://en.wikipedia.org/wiki/Deductiblehttp://en.wikipedia.org/wiki/Out-of-pocket_expenseshttp://en.wikipedia.org/wiki/Copaymenthttp://en.wikipedia.org/wiki/Coinsurance


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drugs) or can apply to all coverage provided during a specific benefit year. Capitation: An amount paid by an insurer to a health care provider, for which the

provider agrees to treat all members of the insurer. In-Network Provider: A health care provider on a list of providers preselected

by the insurer. The insurer will offer discounted coinsurance or copayments, or

additional benefits, to a plan member to see an in-network provider. Generally,providers in network are providers who have a contract with the insurer to acceptrates further discounted from the "usual and customary" charges the insurer paysto out-of-network providers.

Prior Authorization: A certification or authorization that an insurer providesprior to medical service occurring. Obtaining an authorization means that theinsurer is obligated to pay for the service, assume it matches what was authorized.Many smaller, routine services do not require authorization.

Explanation of Benefits: A document sent by an insurer to a patient explainingwhat was covered for a medical service, and how they arrived at the paymentamount and patient responsibility amount.

2.Public health and Health insurance:-

The health care system in India is characterised by multiple systems of medicine, mixedownership patterns and different kinds of delivery structures. Public sector ownership isdivided between central and state governments, municipal and Panchayat localgovernments. Public health facilities include teaching hospitals, secondary levelhospitals, first-level referral hospitals (CHCs or rural hospitals), dispensaries; primaryhealth centres (PHCs), sub-centres and health posts. Also included are public facilities forselected occupational groups like organized work force (ESI), defence, governmentemployees (CGHS), railways, post and telegraph and mines among others. The privatesector (for profit and not for profit) is the dominant sector with 50 per cent of people

seeking indoor care and around 60 to 70 per cent of those seeking ambulatory care (oroutpatient care) from private health facilities. While India has made significant gains interms of health indicators - demographic, infrastructural and epidemiological), itcontinues to grapple with newer challenges. Not only have communicable diseasespersisted over time but some of them like malaria have also developed insecticide-resistant vectors while others like tuberculosis are becoming increasingly drug resistant.HIV / AIDS have of late assumed extremely virulent proportions. The 1990s have alsoseen an increase in mortality on account of non-communicable diseases arising as a resultof lifestyle changes. The country is now in the midst of a dual disease burden ofcommunicable and noncommunicable diseases. This is coupled with spiralling healthcosts, high financial burden on the poor and erosion in their incomes. Around 24% of allPeople hospitalized in India in a single year fall below the poverty line due tohospitalization (World Bank, 2002). An analysis of financing of hospitalization showsthat large proportion of people; especially those in the bottom fourincome quintilesborrow money or sell assets to pay for hospitalization (World Bank, 2002).This situation exists in a scenario where health care is financed through general taxrevenue, community financing, out of pocket payment and social and private healthinsurance schemes. India spends about 4.9% of GDP on health (WHR, 2002). The percapita total expenditure on health in India is US$ 23, of which the per capita Government
http://en.wikipedia.org/wiki/Capitated_reimbursementhttp://en.wikipedia.org/wiki/Capitated_reimbursement


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The history of insurance in India dates back to 1818. It is in this year that the OrientalLife Insurance Company was established in Kolkata to meet the requirements of theEuropean community. During the pre-independent period, India witnessed discriminationamong the life of the Europeans and Indians with more premiums being levied on theIndians. Bombay Mutual Life Assurance Society was the first to charge normal rate

premiums for the Indians. Several insurance companies were set up in India in thebeginning of the 20th Century. The Life Insurance Companies Act was passed in 1912.This act made it mandatory to get the periodical valuations and premium rate tables of thecompanies sanctioned by an actuary. In spite of this, an disparage remained due to thediscrimination between Foreign and Indian companies. National Insurance Company Ltd,established in 1906, is India's oldest insurance company.

3.Insurance Acts in India:-

The Insurance Sector in India is regulated by a number of acts. The insurance Acts inIndia are as follows:

The Insurance Act, 1938

General Insurance Business ( Nationalisation ) Act, 1972

Life Insurance Corporation Act, 1956

Insurance Regulatory and Development Authority (IRDA) Act, 1999

4.Existing schemes:-The health insurance market in India is very limited covering about 10% of the totalpopulation. The existing schemes can be categorized as:(1) Voluntary health insurance schemes or private-for-profit schemes;

(2) Employer-based schemes;(3) Insurance offered by NGOs / community based health insurance, and(4) Mandatory health insurance schemes or government run schemes( namely ESIS, CGHS).

1. Voluntary health insurance schemes or private-for-profit schemes

In private insurance, buyers are willing to pay premium to insurance company that poolspeople with similar risks and insures them for health expenses. The key distinction is thatthe premiums are set at a level, which provides a profit to third party and providerinstitutions. Premiums are based on an assessment of the risk status of the consumer (orof the group of employees) and the level of benefits provided, rather than as a proportion

of the consumers income. In the public sector, the General Insurance Corporation (GIC)and its four subsidiary companies (National Insurance Corporation, New India AssuranceCompany, Oriental Insurance Company and United InsuranceCompany) and the Life Insurance Corporation (LIC) of India provide voluntary Insuranceschemes. The Life Insurance Corporation offers Ashadeep Plan IIand Jeevan Asha PlanII. The General Insurance Corporation offers Personal Accident policy, Jan Arogyapolicy, Raj Rajeshwari policy, Mediclaim policy, Overseas Mediclaim policy, CancerInsurance policy, Bhavishya Arogya policy and Dreaded Disease policy (Srivastava 1999


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as quoted in Bhat R & MalvankarD, 2000) Of the various schemes offered, Mediclaim isthe main product of the GIC. The Medical Insurance Scheme or Mediclaim wasintroduced in November 1986 and it covers individuals and groups with persons aged 580 yrs. Children (3 months 5 yrs) are covered with their parents. This scheme providesfor reimbursement of medical expenses (now offers cashless scheme) by an individual

towards hospitalization and domiciliary hospitalization as per the sum insured. There areexclusions and pre-existing disease clauses. Premiums are calculated based on age andthe sum insured, which in turn varies from Rs 15 000 to Rs 5 00 000.Another scheme, namely the Jan Arogya Bima policy specifically targets the poorpopulation groups. It also covers reimbursement of hospitalization costs up to Rs 5 000annually for an individual premium of Rs 100 a year. The same exclusion mechanismsapply for this scheme as those under the Mediclaim policy. A family discount of 30% isgranted, but there is no group discount or agent commission. However, like theMediclaim, this policy too has had only limited success. The Jan Arogya Bima Schemehad only covered 400 000 individuals by 1997.The year 1999 marked the beginning of a new era for health insurance in the Indian

context. With the passing of the Insurance Regulatory Development Authority Bill(IRDA) the insurance sector was opened to private and foreign participation, therebypaving the way for the entry of private health insurance companies. The Bill alsofacilitated the establishment of an authority to protect the interests of the insuranceholders by regulating, promoting and ensuring orderly growth of the insurance industry.The bill allows foreign promoters to hold paid up capital of up to 26 percent in an Indiancompany and requires them to have a capital of Rs 100 crore along with a business planto begin its operations.Currently, a few companies such as Bajaj Alliance, ICICI, RoyalSundaram, and Cholamandalam among others are offering health insurance schemes. Thenature of schemes offered by these companies is described briefly. Bajaj Allianz: Bajaj Alliance offers three health insurance schemes namely, HealthGuard, Critical Illness Policy and Hospital Cash Daily Allowance Policy.The HealthGuard scheme is available to those aged 5 to 75 years (not allowing entry for those over55 years of age), with the sum assured ranging from Rs 100 0000 to 500 000. It offerscashless benefit and medical reimbursement for hospitalization expenses (preandpost-hospitalization) at various hospitals across India (subject to exclusions andconditions). In case the member opts for hospitals besides the empanelled ones, theexpenses incurred by him are reimbursed within 14 working days from submission of allthe documents. While pre-existing diseases are excluded at the time of taking the policy,they are covered from the 5th year onwards if the policy is continuously renewed for fouryears and the same has been declared while taking the policy for the first time. Otherdiscounts and benefits like tax exemption, health check-up at end of four claims free year,etc. can be availed of by the insured.The Critical Illness policy pays benefits in case theinsured is diagnosed as suffering from any of the listed critical events andsurvives for minimum of 30 days from the date of diagnosis. The illnesses coveredinclude: first heart attack; Coronary artery disease requiring surgery: stroke; cancer;kidney failure; major organ transplantation; multiple sclerosis; surgery on aorta; primarypulmonary arterial hypertension, and paralysis. While exclusion clauses apply, premiumrates are competitive and high-sum insurance can be opted for by the insured.TheHospital Cash Daily Allowance Policy provides cash benefit for each and every


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completed day of hospitalization, due to sickness or accident. The amount payable perday is dependent on the selected scheme. Dependant spouse and children (aged 3 months 21years) can also be covered under the Policy. The benefits payable to the dependantsare linked to that of insured. The Policy pays for a maximum single hospitalization periodof 30 days and an overall hospitalization period of 30/60 completed days per policy

period per person regardless of the number of confinements to hospital/nursing home perpolicy period. ICICI Lombard: ICICI Lombard offers Group Health Insurance Policy. This policy isavailable to those aged 5 80 years, (with children being covered with their parents) andis given to corporate bodies, institutions, and associations. The sum insured is minimumRs 15 000/- and a maximum of Rs 500 000/-. The premium chargeable depends upon theage of the person and the sum insured selected. A slab wise group discount is admissibleif the group size exceeds 100. The policy covers reimbursement of hospitalizationexpenses incurred for diseases contracted or injuries sustained in India. Medical expensesup to 30 days for Pre-hospitalization and up to 60 days for post-hospitalization are alsoAdmissible. Exclusion clauses apply. Moreover, favourable claims experience is

recognized by discount and conversely, unfavourable claims experience attracts loadingon renewal premium. On payment of additional premium, the policy can be extended tocover maternity benefits, pre-existing diseases, and reimbursement of cost of healthcheck-up after four consecutive claims-free years. Royal Sundaram Group: The Shakthi Health Shield policy offered by the RoyalSundaram group can be availed by members of the womens group, their spouses anddependent children. No age limits apply. The premium for adults aged up to 45 years isRs 125 per year, for those aged more than 45 years is Rs 175 per year. Children arecovered at Rs 65 per year. Under this policy, hospital benefits up to Rs 7 000 per annumcan be availed, with a limit per claim of Rs 5 000. Other benefits include maternitybenefit of Rs 3 000 subject to waiting period of nine months after first enrolment and forfirst two children only Cholamandalam General Insurance: The benefits offered (in association with theParamount Health Care, a re-insurer) in case of an illness or accident resulting inhospitalization, are cash-free hospitalization in more than 1 400 hospitals across India,reimbursement of the expenses during pre- hospitalization (60 days prior tohospitalization) and post- hospitalization (90 days after discharge) stages of treatment.Over 130 minor surgeries that require less than 24 hours hospitalization under day careprocedure are also covered. Extra health covers like general health and eye examination,local ambulance service, hospital daily allowance, and 24 hours assistance can be availedof.

2.Employer-based schemes

Employers in both the public and private sector offers employer-based insurance schemesthrough their own employer-managed facilities by way of lump sum payments,reimbursement of employees health expenditure for outpatient care and hospitalization,fixed medical allowance, monthly or annual irrespective of actual expenses, or coveringthem under the group health insurance policy. The railways, defence and security forces,plantations sector and mining sector provide medical services and / or benefits to its own


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employees. The population coverage under these schemes is minimal, about 30-50million people.

3. Insurance offered by NGOs / community-based health insurance

Community-based funds refer to schemes where members prepay a set amount each year

for specified services. The premium are usually flat rate (not income-related) andtherefore not progressive. Making profit is not the purpose of these funds, but ratherimproving access to services. Often there is a problem with adverse selection because ofa large number of high-risk members, since premiums are not based on assessment ofindividual risk status. Exemptions may be adopted as a means of assisting the poor, butthis will also have adverse effect on the ability of the insurance fund to meet the cost ofbenefits. Community-based schemes are typically targeted at poorer populations living incommunities, in which they are involved in defining contribution level and collectingmechanisms, defining the content of the benefit package, and / or allocating the schemes,financial resources. Such schemes are generally run by trust hospitals ornongovernmental organizations (NGOs). The benefits offered are mainly in terms of

preventive care, though ambulatory and in-patient care is also covered. Such schemestend to be financed through patient collection, government grants and donations.Increasingly in India, CBHI schemes are negotiating with the for-profit insurers for thepurchase of custom designed group insurance policies. However, the coverage of suchschemes is low, covering about 30-50 million (Bhat, 1999). A review by Bennett, Cresseet al. (as quoted in Ranson K &Acharya A, 2003) indicates that many community-basedinsurance schemes suffer from poor design and management, fail to include the poorest-of-thepoor, have low membership and require extensive financial support. Other issuesrelate to sustainability and replication of such schemes. Some of the schemes aredescribed below ;- Self-Employed Womens Association (SEWA), Gujarat: This scheme established in1992, provides health, life and assets insurance to women working in the informal sectorand their families. The enrolment in the year 2002 was 93 000. This scheme operates incollaboration with the National Insurance Company (NIC). Under SEWAs most popularpolicy, a premium of Rs 85 per individual is paid by the woman for life, health and assetsinsurance. At an additional payment of Rs 55, her husband too can be covered. Rs 20 permember is then paid to the National Insurance Company (NIC) which provides coverageto a maximum of Rs 2 000 per person per year for hospitalization. After beinghospitalized at a hospital of ones choice (public or private), the insurance claim issubmitted to SEWA. The responsibility for enrolment of members, for processing andapproving of claims rests with SEWA. NIC in turn receives premiums from SEWAannually and pays them a lumpsum on a monthly basis for all claims reimbursed.(Ranson K & Acharya A, 2003). Another CBHI scheme located in Gujarat, is that run by the TribhuvandasFoundation (TF), Anand. This was established in 2001, with the membership beingrestricted to members of the AMUL Dairy Cooperatives. Since then, over 1 00 000households have been enrolled under this scheme, with the TF functioning as a thirdparty insurer.


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The Mallur Milk Cooperative in Karnataka established a CBHI scheme in 1973. Itcovers 7 000 people in three villages and outpatient and inpatient health care are directlyprovided. A similar scheme was established in 1972 at Sewagram, Wardha in Maharashtra. Thisscheme covers about 14 390 people in 12 villages and members are provided with

outpatient and inpatient care directly by Sewagram. The Action for Community Organization, Rehabilitation and Development(ACCORD), Nilgiris, Tamil Nadu was established in 1991. Around 13 000 Adivasis(tribals) are covered under a group policypurchased from New India Assurance. Another scheme located in Tamil Nadu is Kadamalai Kalanjia Vattara Sangam(KKVS), Madurai. This was established in 2000 and coversmembers of womens self-help groups and their families. Its enrolmentin 2002 was around 5 710, with the KKVSfunctioning as a third partyinsurer. The Voluntary Health Services (VHS), Chennai, Tamil Nadu was established in1963. It offers sliding premium with free care to the poorest. The benefits includediscounted rates on both outpatient and inpatient care, with the VHS functioning as both

insurer and health care provider. In 1995, its membership was 124 715. However, thisscheme suffers from low levels of cost recovery due to problems of adverse selection. Raigarh Ambikapur Health Association (RAHA), Chhatisgarh was established in1972, and functions as a third party administrator. Its membership in the year 1993 was72 000.

4.Social Insurance or mandatory health insurance schemes or government

run schemes (namely the ESIS, CGHS)

Social insurance is an earmarked fund set up by government with explicit benefits inreturn for payment. It is usually compulsory for certain groups in the population and thepremiums are determined by income (and hence ability to pay) rather than related tohealth risk. The benefit packages are standardized and contributions are earmarked forspending on health services The government-run schemes include the CentralGovernment Health Scheme (CGHS) and the Employees State Insurance Scheme (ESIS).Central Government Health Scheme (CGHS)

Since 1954, all employees of the Central Government (present and retired); someautonomous and semi-government organizations, MPs, judges, freedom fighters andjournalists are covered under the Central Government Health Scheme (CGHS). Thisscheme was designed to replace the cumbersome and expensive system ofreimbursements (GOI, 1994). It aims at providing comprehensive medical care to theCentral Government employees and the benefits offered include all outpatient facilities,and preventive and promotive care in dispensaries. Inpatient facilities in governmenthospitals and approved private hospitals are also covered. This scheme is mainly fundedthrough Central Government funds, with premiums ranging from Rs 15 to Rs 150 permonth based on salary scales. The coverage of this scheme has grown substantially withprovision for the non-allopathic systems of medicine as well as for allopathy.Beneficiaries at this moment are around 432 000, spread across 22 cities. The CGHS hasbeen criticized from the point of view of quality and accessibility. Subscribers havecomplained of high out-of-pocket expenses due to slow reimbursement and incomplete


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coverage for private health care (as only 80% of cost is reimbursed if referral is made toprivate facility when such facilities are not available with the CGHS).

Employee and State Insurance Scheme (ESIS)

The enactment of the Employees State Insurance Act in 1948 led to formulation of theEmployees State Insurance Scheme. This scheme provides protection to employeesagainst loss of wages due to inability to work due to sickness, maternity, disability anddeath due to employment injury. It offers medical and cash benefits, preventive andpromotive care and health education. Medical care is also provided to employees andtheir family members without fee for service. Originally, the ESIS scheme covered allpower-using non-seasonal factories employing 10 or more people. Later, it was extendedto cover employees working in all non-power using factories with 20 or more persons.While persons working in mines and plantations, or an organization offering healthbenefits as good as or better than ESIS, are specifically excluded. Service establishmentslike shops, hotels, restaurants, cinema houses, road transport and news papers printing are

now covered. The monthly wage limit for enrolment in the ESIS is Rs. 6 500, with aprepayment contribution in the form of a payroll tax of 1.75% by employees, 4.75% ofemployees' wages to be paid by the employers, and 12.5% of the total expenses are borneby the state governments. The number of beneficiaries is over 33 million spread over 620ESI centres across states. Under the ESIS, there were 125 hospitals, 42 annexes and 1 450dispensaries with over 23 000 beds facilities. The scheme is managed and financed by theEmployees State Insurance Corporation (a public undertaking) through the stategovernments, with total expenditure of Rs 3 300 million or Rs 400/- per capita insuredperson.The ESIS programme has attracted considerable criticism. A report based onpatient surveys conducted in Gujarat (Shariff, 1994 as quoted in Ellis R et a, 2000) foundthat over half of those covered did not seek care from ESIS facilities. Unsatisfactorynature of ESIS services, low quality drugs, long waitingperiods, impudent behaviour ofpersonnel, lack of interest or low interest onpart of employees and low awareness of ESIprocedures, were some of thereasons cited.Other Government Initiatives

Apart from the government-run schemes, social security benefits for the disadvantagedgroups can be availed of, under the provisions of the Maternity Benefit (Amendment) Act1995, Workmens Compensation (Amendment) Act 1984, Plantation Labour Act 1951,Mine Mines Labour Welfare Fund Act 1946, Beedi Workers Welfare Fund Act 1976 andBuilding and other Construction Workers (Regulation of Employment and Conditions ofService) Act, 1996. The Government of India has also undertaken initiatives to addressissues relating to access to public health systems especially for the vulnerable sections ofthe society. The National Health Policy 2002 acknowledges this and aims to evolve apolicy structure, which reduces such inequities and allows the disadvantaged sections ofthe population a fairer access to public health services. Ensuring more equitable access tohealth services across the social and geographical expanse of the country is the mainobjective of the policy. It also seeks to increase the aggregate public health investmentthrough increased contribution from the Central as well as state governments andencourages the setting up of private insurance instruments for increasing the scope ofcoverage of the secondary and tertiary sector under private health insurance packages.


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The government envisages an increase in health expenditure as a % of GDP from existing0.9% to 2.0 % by 2010 and an increase in the share of central grants from the existing15% to constitute at least 25% of total public health spending by 2010. The Stategovernment spending for health in turn would increase from 5.5% to 7% of the budget by2005, to be further increased to 8% by 2010. The National Population Policy (NPP) 2000,

envisages the establishment of a family welfare-linked health insurance plan. As per thisplan, couples living below the poverty line who undergo sterilization with not more thantwo living children would be eligible for insurance. Under this scheme, the couple alongwith their children would be covered for hospitalization not exceeding Rs 5 000 and apersonal accident insurance cover for the spouse undergoing sterilization. The Institute ofHealth Systems (IHS), Hyderabad has been entrusted the responsibility ofoperationalizing the mandate of the NPP 2000. The initial scheme proposed by the HISwas discussed at a workshop in June 2003. The consensus at the meeting was that thescheme, needed further improvement prior to its implementation even as a pilot project.In keeping with the recommendations of the Tenth Five Year Plan and the NationalHealth Policy (NHP) 2002, the Department of Family Welfare is also proposing to

commission studies in eight states covering eight districts, to generate district-specificdata, which is essential for conceptualization of a reasonable and financially viableinsurance scheme. The current plan the Tenth Five Year Plan (2002-07) - also focuseson exploring alternative systems of health care financing including health insurance sothat essential, need-based and affordable health care is available to all. The urgent need toevolve, implement and evaluate an appropriate scheme for health financing for differentincome groups is acknowledged. In the past, the government has tried to ensure that thepoor get access to private health facilities through subsidy in the form of duty exemptionsand other such benefits. Social health insurance for families living below the poverty linehas been suggested as a mechanism for reducing the adverse economic consequences ofhospitalization and treatment for chronic ailments requiring expensive and continuouscare. In the budget for the year 2002-2003, an insurance scheme called Janraskha wasintroduced, with the aim of providing protection to the needy population. With apremium of Re 1/- per day, it ensured indoor treatment up to Rs 3 000 per year at selectedand designated hospitals and outpatient treatment up to Rs 2 000 per year at designatedclinics, including civil hospitals, medical colleges, private trust hospitals and other NGO-run institutions. A few states have started implementing this scheme under pilot phase. Inthe budget for the period 2003-2004, another initiative of community-based healthinsurance has been announced. This scheme aims to enable easy access of lessadvantaged citizens to good health services, and to offer health protection to them. Thispolicy covers people between the age of three months to 65 years. Under this scheme, apremium equivalent to Re 1 per day (or Rs 365 per year) for an individual, Rs 1.50 perday for a family of five (or Rs 548 per year), and Rs 2 per day for a family of seven (orRs 730 per year), would entitle them to get reimbursement of medical expenses up toRs 30 000 towards hospitalization, a cover for death due to accident for Rs 25000 andcompensation due to loss of earning at the rate of Rs 50 per day up to a maximum of 15days. The government would contribute Rs 100 per year towards the annual premium, soas to ensure the affordability of the scheme to families living below the poverty line. Theimplementation of this scheme rests with the four public sector insurance companies.


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The government also offers assistance by way of Illness Assistance Funds, which havebeen set up by the Ministry of Health and Family Welfare at the national level and in afew states. State Illness Assistance Funds exist in Andhra Pradesh, Bihar, Goa, Gujarat,Himachal Pradesh, Jammu and Kashmir, Karnataka, Kerala, Madhya Pradesh,Maharashtra, Mizoram, Rajasthan, Sikkim, Tamil Nadu, Tripura, West Bengal, NCT of

Delhi and UT of Pondicherry. A National Illness Assistance Fund (NIAF) was set up in1997, with the scheme being reviewed in January 1998. Through this, three CentralGovernment hospitals and three national-level institutes have been sanctioned Rs 10 00000 each at a time from the NIAF to provide immediate financial assistance to the extentof Rs 25 000 per case to poor patients living below the poverty line and who areundergoing treatment in these hospitals / institutions. Thereafter the scheme has beenextended to few other institutes across the country and provides Rs 25 000 Rs 50 000per case.Health insurance initiatives by State Governments

In the recent past, various state governments have begun health insurance initiatives. Forinstance, the Andhra Pradesh government is implementing the Aarogya Raksha Scheme

since 2000, with a view to increase the utilization of permanent methods of familyplanning by covering the health risks of the acceptors. All people living below thepoverty line and those who accept permanent methods of family planning are eligible tobe covered under this scheme. The Government of Andhra Pradesh pays a premium of Rs75 per acceptor. The benefits to be availed of, include hospitalization costs up to Rs. 4000per year for the acceptor and for his / her two children for a total period of five yearsfrom date of the family planning operation. The coverage is for common illnesses andaccident insurance benefits are also offered. The hospital bill is directly reimbursed bythe Insurance Company, namely the New India Assurance Company. The Government ofGoa along with the New India Assurance Company in 1988 developed a medicalreimbursement mechanism. This scheme can be availed by all permanent residents ofGoa with an income below Rs 50 000 per annum for hospitalization care, which is notavailable within the government system. The non-availability of services requirescertification from the hospital Dean or Director Health Services. The overall limit isRs 30 000for the insured person for a period of one year. A pilot project on health

insurance was launched by the Government of Karnataka and the UNDP in two blockssince October 2002. The aim of the project was to develop and test a model ofcommunity health financing suited for rural community, thereby increasing the access tomedical care of the poor. The beneficiaries include the entire population of these blocks.The premium is Rs 30 per person per year, with the Government of Karnatakasubsidizing the premium of those below poverty line and those belonging to ScheduledCastes/ Scheduled Tribes. This premium entitles them to hospitalization coverage in thegovernment hospitals up to a maximum of Rs 2500 per year, including hospitalization forcommon illnesses, ambulance charges, loss of wages at Rs. 50 per day as well as drugexpenses at Rs 50 per day. Reimbursements are made to an insurance fund which hasbeen set up by the NGO / PRI with the support of UNDP.

The Government of Kerala is planning to launch a pilot project of health insurance for the30% families living below the poverty line. The scheme would be associated with agovernment insurance company. Currently, negotiations are under way with the


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IRA to seek service tax exemption. The proposed premium is Rs 250 plus 5% tax.The maximum benefit per family would be Rs 20 000. The amount for the premiumwould be recovered from the drug budget (Rs 100), the PRI (Rs 100) and from thebeneficiary (Rs 62.50) while the benefits available would include cover forhospitalization, deliveries involving surgical procedures (either to the mother or the

newborn). Instead of payment by the beneficiary, Smart Card facility would beoffered. This scheme would be applicable in 216 government hospitals.

6. Comparison:-

Australia

The public health system is called Medicare. It ensures free universal access to hospitaltreatment and subsidized out-of-hospital medical treatment. It is funded by a 1.5%tax levy.The private health system is funded by a number of private healthinsurance organizations. The largest of these is Medibank Private, which is

government-owned, but operates as a government business enterprise under thesame regulatory regime as all other registered private health funds. The CoalitionHoward government had announced that Medibank would be privatised if it wonthe 2007 election, however they were defeated by the Australian Labor Partyunder Kevin Rudd which had already pledged that it would remain ingovernment ownership.Some private health insurers are 'for profit' enterprises,and some are non-profit organizations such as HCF Health Insurance. Somehave membership restricted to particular groups, but the majorities have openmembership.Most aspects of private health insurance in Australia are regulated bythe Private Health Insurance Act 2007.The private health system in Australiaoperates on a "community rating" basis, whereby premiums do not vary solely

because of a person's previous medical history, current state of health, or(generally speaking) their age (but see Lifetime Health Cover below). Balancingthis are waiting periods, in particular for pre-existing conditions (usually referredto within the industry as PEA, which stands for "pre-existing ailment"). Funds areentitled to impose a waiting period of up to 12 months on benefits for any medicalcondition the signs and symptoms of which existed during the six months endingon the day the person first took out insurance. They are also entitled to impose a12-month waiting period for benefits for treatment relating to an obstetriccondition, and a 2-month waiting period for all other benefits when a person firsttakes out private insurance. Funds have the discretion to reduce or remove suchwaiting periods in individual cases. They are also free not to impose them tobegin with, but this would place such a fund at risk of "adverse selection",attracting a disproportionate number of members from other funds, or from thepool of intending members who might otherwise have joined other funds. Itwould also attract people with existing medical conditions, who might nototherwise have taken out insurance at all because of the denial of benefits for 12months due to the PEA Rule. The benefits paid out for these conditions wouldcreate pressure on premiums for all the fund's members, causing some to droptheir membership, which would lead to further rises, and a vicious cycle would
http://en.wikipedia.org/wiki/Medicare_(Australia)http://en.wikipedia.org/wiki/Medibank_Privatehttp://en.wikipedia.org/wiki/Government_business_enterprisehttp://en.wikipedia.org/wiki/Coalition_(Australia)http://en.wikipedia.org/wiki/John_Howardhttp://en.wikipedia.org/wiki/Australian_federal_election,_2007http://en.wikipedia.org/wiki/Australian_Labor_Partyhttp://en.wikipedia.org/wiki/Kevin_Ruddhttp://en.wikipedia.org/wiki/Non-profit_organizationhttp://en.wikipedia.org/wiki/HCF_Health_Insurancehttp://en.wikipedia.org/wiki/HCF_Health_Insurancehttp://en.wikipedia.org/wiki/Medicare_(Australia)http://en.wikipedia.org/wiki/Medibank_Privatehttp://en.wikipedia.org/wiki/Government_business_enterprisehttp://en.wikipedia.org/wiki/Coalition_(Australia)http://en.wikipedia.org/wiki/John_Howardhttp://en.wikipedia.org/wiki/Australian_federal_election,_2007http://en.wikipedia.org/wiki/Australian_Labor_Partyhttp://en.wikipedia.org/wiki/Kevin_Ruddhttp://en.wikipedia.org/wiki/Non-profit_organizationhttp://en.wikipedia.org/wiki/HCF_Health_Insurance


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ensue.There are a number of other matters about which funds are not permitted todiscriminate between members in terms of premiums, benefits or membership -these include racial origin, religion, sex, sexual orientation, nature ofemployment, and leisure activities. Premiums for a fund's product that is sold inmore than one state can vary from state to state, but not within the same state.

The Australian government has introduced a number of incentives to encourage adults totake out private hospital insurance. These include:

Lifetime Health Cover: If a person has not taken out private hospital cover bythe 1st July after their 30th birthday, then when (and if) they do so after this time,their premiums must include a loading of 2% per annum. Thus, a person takingout private cover for the first time at age 40 will pay a 20 per cent loading. Theloading continues for 10 years. The loading applies only to premiums for hospitalcover, not to ancillary (extras) cover.

Medicare Levy Surcharge: People whose taxable income is greater than aspecified amount (currently $70,000 for singles and $140,000 for couples) andwho do not have an adequate level of private hospital cover must pay a 1%surcharge on top of the standard 1.5% Medicare Levy. The rationale is that if thepeople 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 abenefit in the event that they need private hospital treatment - rather than pay it inthe form of extra tax as well as having to meet their own private hospital costs.The Australian government announced in May 2008 that it proposes to increasethe thresholds, to $100,000 for singles and $150,000 for families. These changesrequire legislative approval. A bill to change the law has been introduced but was

not passed by the Senate. A changed version was passed on 16 October 2008.There have been criticisms that the changes will cause many people to drop theirprivate health insurance, causing a further burden on the public hospital system,and a rise in premiums for those who stay with the private system. Othercommentators believe the effect will be minimal.

Private Health Insurance Rebate: The government subsidizes the premiums forall private health insurance cover, including hospital and ancillary (extras), by30%, 35% or 40%.

Canada

Most health insurance in Canada is administered by each province, under the CanadaHealth Act, which requires all people to have free access to basic health services.Collectively, the public provincial health insurance systems in Canada arefrequently referred to as Medicare. Private health insurance is allowed, but theprovincial governments allow it only for services that the public health plans donot cover; for example, semi-private or private rooms in hospitals and prescriptiondrug plans. Canadians are free to use private insurance for elective medical
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services such as laser vision correction surgery, cosmetic surgery, and other non-basic medical procedures. Some 65% of Canadians have some form ofsupplementary private health insurance; many of them receive it through theiremployers. Private-sector services not paid for by the government account fornearly 30 percent of total health care spending.

In 2005, the Supreme Court of Quebec ruled, in Chaoulli v. Quebec, that the province'sprohibition on private insurance for health care already insured by the provincial plancould constitute an infringement of the right to life and security if there were long waittimes for treatment as happened in this case. Certain other provinces have legislationwhich financially discourages but does not forbid private health insurance in areascovered by the public plans. The ruling has not changed the overall pattern of healthinsurance across Canada but has spurred on attempts to tackle the core issues of supplyand demand and the impact of wait times.

France

The French model of health insurance has been ranked by the World Health Organisationas the best in the world, because it permits a high quality of care and nearly total patientfreedom. The national system of health insurance was instituted in 1945, just after the endof the Second World War. It was a compromise between Gaullist and Communistrepresentatives in the French parliament. The Conservative Gaullists were opposed to astate-run healthcare system, while the Communists were supportive of a completenationalisation of health care along a British Beveridge model. The resulting programmewas profession-based : all people working were required to pay a portion of their incometo a health insurance fund, which mutualised the risk of illness, and which reimbursedmedical expenses at varying rates. Children and spouses of insured people were eligible

for benefits, as well. Each fund was free to manage its own budget and reimburse medicalexpenses at the rate it saw fit.

The government has two responsibilities in this system.

The first government responsibility is the fixing of the rate at which medicalexpenses should be negotiated, and it does this in two ways: The Ministry ofHealth directly negotiates prices of medicine with the manufacturers, based on theaverage price of sale observed in neighboring countries. A board of doctors andexperts decides if the medicine provides a valuable enough medical benefit to bereimbursed (note that most medicine is reimbursed, including homeopathy). Inparallel, the government fixes the reimbursement rate for medical services : thismeans that a doctor is free to charge the fee that he wishes for a consultation or anexamination, but the social security system will only reimburse it at a pre-set rate.These tariffs are set annually through negotiation with doctors' representativeorganisations.

The second government responsibility is oversight of the health-insurance funds,to ensure that they are correctly managing the sums they receive, and to ensureoversight of the public hospital network.
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Today, this system is more-or-less intact. All citizens and legal foreign residents ofFrance are covered by one of these mandatory programs, which continue to be funded byworker participation. However, since 1945, a number of major changes have beenintroduced. Firstly, the different health-care funds (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 amandatory regime (those who have never worked and who are not students, meaning thevery rich or the very poor). This regime, unlike the worker-financed ones, is financed viageneral taxation and reimburses at a higher rate than the profession-based system forthose 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 requireinsured people to declare a referring doctor in order to be fully reimbursed for specialistvisits, 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 $) perday for hospital stays and for expensive procedures.

An important element of the French insurance system is solidarity : the more ill a personbecomes, the less they pay. This means that for people with serious or chronic illnesses,the insurance system reimburses them 100 % of expenses, and waives their co-paycharges.

Finally, for fees that the mandatory system does not cover, there is a large range ofprivate complementary insurance plans available. The market for these programs is verycompetitive, and often subsidised by the employer, which means that premiums areusually modest. 85% of French people benefit from complementary private healthinsurance.

Netherlands

In 2006, a new system of health insurance came into force in the Netherlands. This newsystem avoids the two pitfalls of adverse selection and moral hazard associated withtraditional forms of health insurance by using a combination of regulation and aninsurance equalization pool. Moral hazard is avoided by mandating that insurancecompanies provide at least one policy which meets a government set minimum standardlevel of coverage, and all adult residents are obliged by law to purchase this coveragefrom an insurance company of their choice. All insurance companies receive funds fromthe equalization pool to help cover the cost of this government-mandated coverage. Thispool 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 tocover people who cannot afford health care, which makes up an additional 5%. Theremaining 45% of health care funding comes from insurance premiums paid by thepublic, for which companies compete on price, though the variation between the variouscompeting insurers is only about 5%. However, insurance companies are free to selladditional policies to provide coverage beyond the national minimum. These policies donot receive funding from the equalization pool, but cover additional treatments, such asdental procedures and physiotherapy, which are not paid for by the mandatory policy.
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Funding from the equalization pool is distributed to insurance companies for each personthey insure under the required policy. However, high-risk individuals get more from thepool, and low-income persons and children under 18 have their insurance paid forentirely. Because of this, insurance companies no longer find insuring high riskindividuals an unappealing proposition, avoiding the potential problem of adverse

selection.

Insurance companies are not allowed to have co-payments, caps, or deductibles, or todeny coverage to any person applying for a policy, or to charge anything other than theirnationally set and published standard premiums. Therefore, every person buyinginsurance will pay the same price as everyone else buying the same policy, and everyperson will get at least the minimum level of coverage.

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 insurancesystem because (a) there are no premiums collected, (b) costs are not charged at thepatient level and (c) costs are not pre-paid from a pool. However, it does achieve themain aim of insurance which is to spread financial risk arising from ill-health. The costsof running the NHS (est. 104 billion in 2007-8)[28] are met directly from generaltaxation. The NHS provides the majority of health care in the UK, including primarycare, in-patient care, long-term health care, ophthalmology and dentistry.

Private health care has continued parallel to the NHS, paid for largely by privateinsurance, but it is used by less than 8% of the population, and generally as a top-up toNHS services. There are many treatments that the private sector does not provide. For

example, health insurance on pregnancy is generally not covered or covered withrestricting clauses.[29] One of the major insurers, BUPA, excludes many forms oftreatment and care that most people will need during their lifetime or specialist care mostof which are freely available from the NHS. These include:- ageing, menopause andpuberty; AIDS/HIV; allergies or allergic disorders; birth control, conception, sexualproblems and sex changes; chronic conditions; complications from excluded or restrictedconditions/ 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 andrepatriation; physical aids and devices; pre-existing or special conditions; pregnancy andchildbirth; screening and preventive treatment; sleep problems and disorders; speechdisorders; temporary relief of symptoms ( = except in exceptional circumstances)

Recently the private sector has been used to increase NHS capacity despite a largeproportion of the British public opposing such involvement. According to the WorldHealth Organization, government funding covered 86% of overall health care
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expenditures in the UK as of 2004, with private expenditures covering the remaining14%.

United States

The US market-based health care system relies heavily on private and not-for-profithealth insurance, which is the primary source of coverage for most Americans. Accordingto the United States Census Bureau, approximately 84% of Americans have healthinsurance; some 60% obtain it through an employer, while about 9% purchase it directly.Various government agencies provide coverage to about 27% of Americans (there issome overlap in these figures).

Public programs provide the primary source of coverage for most seniors and for low-income children and families who meet certain eligibility requirements. The primarypublic programs are Medicare, a federal social insurance program for seniors and certaindisabled individuals, Medicaid, funded jointly by the federal government and states but

administered at the state level, which covers certain very low income children and theirfamilies, and SCHIP, also a federal-state partnership that serves certain children andfamilies who do not qualify for Medicaid but who cannot afford private coverage. Otherpublic programs include military health benefits provided through TRICARE and theVeterans Health Administration and benefits provided through the Indian Health Service.Some states have additional programs for low-income individuals.

In 2006, there were 47 million people in the United States (16% of the population) whowere without health insurance for at least part of that year. About 37% of the uninsuredlive in households with an income over $50,000.[

In 2004, US health insurers directly employed almost 470,000 people at an average salaryof $61,409. (As of the fourth quarter of 2007, the total US labor force stood at 153.6million, of whom 146.3 million were employed. Employment related to all forms ofinsurance totaled 2.3 million. Mean annual earnings for full-time civilian workers as ofJune 2006 were $41,231; median earnings were $33,634.) The insurance industry alsorepresents a significant lobbying group in the US. For 2008 insurance was the 8th amongindustries in political contributions to members of Congress, giving $28,654,121, ofwhich 51% was given to Democrats and 49% to Republicans, with the top recipient ofinsurance industry contributions being Senator John McCain (R-AZ). The leadingcontributor from the insurance industry as measured by total political contributions was AFLAC, Inc., which contributed $907,150 in 2007.

7. Conclusions:-

There are few issues of concern or barriers towards implementing a social healthinsurance scheme in India. These are enumerated below along with the possible wayahead. India is a low-income country with 26% population living below the poverty line,and 35% illiterate population with skewed health risks. Insurance is limited to only a
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small proportion of people in the organized sector covering less than 10% of the totalpopulation. Currently, there no mechanism or infrastructure for collecting mandatorypremium among the large informal sector. Even in terms of the existing schemes, there isinsufficient and inadequate information about the various schemes. Data gaps alsoprevail. Much of the focus of the existing schemes is on hospital expenses. There

continues to be lack of awareness among people about health insurance. In spite ofexisting regulation in some States, the private sector continues to operate in an almostunhindered manner. The growth of health insurance increases the need for licensing andregulating private health providers and developing specific criteria to decide uponappropriate services and fees. Health insurance per se, suffers from problems like adverseselection, moral hazard, cream-skimming and high administrative costs. This is coupledwith the fact that in the absence of any costing mechanisms, there is difficulty incalculating the premium. There is also a need to evolve criteria to be used for decidingupon target groups, who would avail of the SHI scheme/s and also to address issuesrelating to whether indirect costs would be included in health insurance. Health insurancecan improve access to good quality health care only if it is able to provide for health care

institutions with adequate facilities and skilled personnel at affordable cost. Given thisscenario, the challenge, then, for Indian policy-makers is to find ways to improve uponthe existing situation in the health sector and to make equitable, affordable and qualityhealth care accessible to the population, especially the poor and the vulnerable sections ofthe society. It is in a way inevitable that the state reforms its public health deliverysystem and explores other social security options like health insurance. Implementingregulations would be one, but by no means the best mechanism to contain providerbehaviour and costs. This can only be done by developing mechanisms wheregovernment and households can together pool their funds. This could be one way ofcontrolling provider behaviour. There is an urgent need to document global and Indianexperiences in social health insurance. Different financing options would need to bedeveloped for different target groups. The wide differentials in the demographic,epidemiological status and the delivery capacity of health systems are a serious constraintto a nationally mandated health insurance system. Given the heterogeneity of differentregions in India and the regional specifications, one would need to undertake pilotprojects to gather more information about the population to be targeted under aninsurance scheme and develop options for different population groups. Health policy-makers and health systems research institutions, in collaboration with economic policystudy institutes, need to gather information about the prevailing disease burden at variousgeographical regions; to develop standard treatment guidelines, to undertake costing ofhealth services for evolving benefit packages to determine the premium to be levied andsubsidies to be given; and to map health care facilities available and the institutionalmechanisms which need to be in place, for implementing health insurance schemes.Skillbuilding for the personnel involved, and capacity-building of all the stakeholdersinvolved, would be a critical component for ensuring the success of any health insuranceprogramme. The success of any social insurance scheme would depend on its design, theimplementation and monitoring mechanisms which would be set in place and it wouldalso call for restructuring and reforming the health system, and developing the necessaryprerequisites to ensure its success.


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8. References:-

1. Bhat Ramesh & Mavlankar Dileep (2000), Health Insurance in India:Opportunities, Challenges and Concerns, Indian Institute of Management,Ahmedabad.

2. Bhat Ramesh (1999), A note on policy initiatives to protect the poor from high

medical costs, Indian Institute of Management, Ahmedabad.3. Ellis Randal et al (2000), Health Insurance in India: Prognosis & Prospectus,Economic & Political Weekly, January 22, pp. 207-216

4. Government of India (1994), Annual Report, 1993-94,Ministry of Health &Family Welfare

5. Krause Patrick (2000), Non-profit Insurance Schemes for the Unorganized Sectorin India, Social Policy Division 42, Working Papers No. 22 e, GTZ

6. Peters David et al, (2002) Better Health Systems for Indias Poor: Findings,Analysis, and Options, Health, Nutrition, and Population Series, World Bank:Washington DC.

7. Ranson Kent & Acharya Akash (2003), Community based health insurance: The

Answer to Indias Risk Sharing Problems? Health Action, March. .Ranson Kent& Jowett Matthew (2003), Developing Health Insurance in India:

8. (World Health Organization (2002), World Health Report 2002: Reducing risks,promoting healthy life, WHO: Geneva.

9. How Private Insurance Works: A Primerby Gary Claxton, Institution for HealthCare Research and Policy, Georgetown University, on behalf of the Henry J.Kaiser Family Foundation

10. Howstuffworks: How Health Insurance WorksEncarta: Health Insurance11. See California Insurance Code Section 106 (defining disability insurance). In

2001, the California Legislature added subdivision (b), which defines "healthinsurance" as "an individual or group disability insurance policy that providescoverage for hospital, medical, or surgical benefits."

12. Fundamentals of Health Insurance: Part A, Health Insurance Association ofAmerica, 1997, ISBN 1-879143-36-4

13. Thomas P. O'Hare, "Individual Medical Expense Insurance," The AmericanCollege, 2000, page 7, ISBN 1-57996-025-1

14. Managed Care: Integrating the Delivery and Financing of Health Care - Part A,Health Insurance Association of America, 1995, page 9 ISBN 1-879143-26-1

15. Agency for Healthcare Research and Quality (AHRQ). "Questions and AnswersAbout Health Insurance: A Consumer Guide." August 2007.

16. http://www.brainypatient.com/HealthInsPriorAuth.html17. http://www.brainypatient.com/HealthInsReadingEOB.html18. "Comprehensive Health Insurance vs. Scheduled Health Insurance"19. "Mini Medical Plans On The Move"20. "Wading Through Medical Insurance Pools: A Primer," American Academy of

Actuaries September 2006 http://www.actuary.org/pdf/health/pools_sep06.pdf
http://www.kff.org/insurance/upload/How-Private-Insurance-Works-A-Primer-Report.pdfhttp://health.howstuffworks.com/health-insurance1.htmhttp://ca.encarta.msn.com/encyclopedia_761576408_8/Health_Insurance.html#s49http://en.wikipedia.org/wiki/California_Legislaturehttp://en.wikipedia.org/wiki/Special:BookSources/1879143364http://en.wikipedia.org/wiki/Special:BookSources/1579960251http://en.wikipedia.org/wiki/Special:BookSources/1579960251http://en.wikipedia.org/wiki/Special:BookSources/1879143261http://www.ahrq.gov/consumer/insuranceqa/http://www.ahrq.gov/consumer/insuranceqa/http://www.brainypatient.com/HealthInsPriorAuth.htmlhttp://www.brainypatient.com/HealthInsReadingEOB.htmlhttp://www.healthinsurancequotesamerica.com/http://www.cahi.org/article.asp?id=415http://en.wikipedia.org/wiki/American_Academy_of_Actuarieshttp://en.wikipedia.org/wiki/American_Academy_of_Actuarieshttp://www.actuary.org/pdf/health/pools_sep06.pdfhttp://www.kff.org/insurance/upload/How-Private-Insurance-Works-A-Primer-Report.pdfhttp://health.howstuffworks.com/health-insurance1.htmhttp://ca.encarta.msn.com/encyclopedia_761576408_8/Health_Insurance.html#s49http://en.wikipedia.org/wiki/California_Legislaturehttp://en.wikipedia.org/wiki/Special:BookSources/1879143364http://en.wikipedia.org/wiki/Special:BookSources/1579960251http://en.wikipedia.org/wiki/Special:BookSources/1879143261http://www.ahrq.gov/consumer/insuranceqa/http://www.ahrq.gov/consumer/insuranceqa/http://www.brainypatient.com/HealthInsPriorAuth.htmlhttp://www.brainypatient.com/HealthInsReadingEOB.htmlhttp://www.healthinsurancequotesamerica.com/http://www.cahi.org/article.asp?id=415http://en.wikipedia.org/wiki/American_Academy_of_Actuarieshttp://en.wikipedia.org/wiki/American_Academy_of_Actuarieshttp://www.actuary.org/pdf/health/pools_sep06.pdf


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21. Marc L. Berk and Alan C. Monheit, "The Concentration Of Health CareExpenditures, Revisited", Health Affairs, Volume 20, Number 2, March/April2001. Accessed February 27, 2008.

22. Marc L. Berk and Alan C. Monheit, "Datawatch: The Concentration Of HealthExpenditures: An Update", Health Affairs, Winter 1992. Accessed February 27,

2008.23. "19971999 Group Medical Insurance Database and Analysis Report," Society ofActuaries, 2004

24. "The Bottom Line on Risk Classification in Individually Purchased VoluntaryMedical Expense Insurance," American Academy of Actuaries, February 1999

25. Teresa Chovan, Hannah Yoo and Tom Wildsmith,"Individual Health Insurance: AComprehensive Survey of Affordability, Access, and Benefits"Americas HealthInsurance Plans, August 2005.

26. Teresa Chovan, Hannah Yoo and Tom Wildsmith,Individual Health Insurance: AComprehensive Survey of Affordability, Access, and Benefits, Americas HealthInsurance Plans, Table 7, page 11 (Note that the remainder, roughly 2%, received

other types of offers, such as policies with condition waivers).27. Task Force on Genetic Testing in Health Insurance,"Risk Classification inIndividually Purchased Voluntary Medical Expense Insurance," AmericanAcademy of Actuaries, February 1999

28. The Factors Fueling Rising Healthcare Costs 2006, PriceWaterhouseCoopers forAmerica's Health Insurance Plans, 2006, accessed 2007-10-08

29. Private Health Insurance in OECD Countries.OECD Health Project. 2004.30. "National Health Expenditure Trends, 1975-2007". Canadian Institute for Health

Information. 2007-11-13.31. Hadorn, D. (2005-08-02). "The Chaoulli challenge: getting a grip on waiting

lists". Canadian Medical Association Journal^"L'assurance maladie"32. John S. Ambler, "The French Welfare State : surving social and ideological

change," New York University Press, 30 Sept 1993,ISBN 978-081470626833. HM Treasury (2007-03-21). "Budget 2007".34. "Bupa, AXA, Pru Health and Aviva (Norwich Union) Health Insurance on

Pregnancy".35. http://www.bupa.co.uk/heartbeat/html/not_covered.html BUPA exclusions36. "Survey of the general public's views on NHS system reform in England". 2007-

06-01.37. World Health Organization Statistical Information System: Core Health Indicators38. "Income, Poverty, and Health Insurance Coverage in the United States: 2006."

U.S. Census Bureau. Issued August 2007.39. U.S. Census Bureau,"CPS Health Insurance Definitions"40. "Health Insurance: Overview and Economic Impact in the States," Americas

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