202-Personal Insurance Final

8/6/2019 202-Personal Insurance Final

http://slidepdf.com/reader/full/202-personal-insurance-final 1/29

Page 1

CHAPTER-1

PROLOGUE

At the outset, I would like to introduce title of my project. That is “Comparison of various health

insurance products”. In the current scenario, medical expenses cannot be afforded and in addition it is still

going sky high in a rapid force. In short, we can say it's already gone out of the reach of common people‟s

budget. Here insurance is in; it saves money and covers unexpected calamities. It covers you for

hospitalization expenses, pre and post hospitalization expenses, day care procedures, etc.

The importance of health insurance cannot be measured. Today, many health insurance providers are in the

market to offer health plans with attractive rates and discounts. But, beware for the coverage limit, it might be

shorten by the price and your necessary requirements are not included in the policy.so my project work is to

compare all various health insurance products available in the Indian market offered by different companies with

different names and make out merits and demerits of different products.

1.1 Research methodology

The topic of project is “comparison of various Health insurance Products”. The researcher has used the doctrinal

method of research to give a sound exposure to the present topic. The researcher has made use secondary data

primarily. Books are the primary source of secondary data. The data so obtained has been used

appropriately and effectively. The NALSAR-IIRM library has been used for the secondary sources. This method

includes collective information from various resources, books authored by experts of related subject and status

books.

1.2 Research Plan

The project is tries to cover various types of health insurance products in general and various products of general

insurance companies present in India. Through this project the researcher aims to provide the reader with a

detailed overview of various health insurance products offered by the different companies due to paucity of space

and time to some extent, the researcher will be unable to include all the matter and limit him-self to analysing and

discussing only the relevant matter directly related to the topic. The researcher has carefully scrutinized the

mentioned topic and given a brief study on the same

_____________________________________________________________________________

1. http://www.articlesbase.com/insurance-articles/importance-of-health-insurance.



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CHAPTER-2

HEALTHCARE IN INDIA

Healthcare in India features a universal health care system run by the constituent states and territories of India.

The Constitution charges every state with "rising of the level of nutrition and the standard of living of its people

and the improvement of public health as among its primary duties". The National Health Policy was endorsed by

the Parliament of India in 1983 and updated in 20022. However, the government sector is understaffed and

underfinanced; poor services at state-run hospitals force many people to visit private medical practitioners.

Government hospitals, some of which are among the best hospitals in India, provide treatment at taxpayer

expense. Most essential drugs are offered free of charge in these hospitals. Government hospitals provide

treatment either free or at minimal charges. For example, an outpatient card at AIIMS (one of the best hospitals in

India) costs a one-time fee of rupees 10 (around 20 cents US) and thereafter outpatient medical advice is free. In-

hospital treatment costs depend on financial condition of the patient and facilities utilized by him but are usually

much less than the private sector. For instance, a patient is waived treatment costs if he is below poverty line.

Another patient may seek for an air-conditioned room if he is willing to pay extra for it. The charges for basic in-

hospital treatment and investigations are much less compared to the private sector. The cost for these subsidies

comes from annual allocations from the central and state governments.

Primary health care is provided by city and district hospitals and rural primary health centres (PHCs). These

hospitals provide treatment free of cost. Primary care is focused on immunization, prevention of malnutrition,

pregnancy, child birth, postnatal care, and treatment of common illnesses. Patients who receive specialized care or

have complicated illnesses are referred to secondary (often located in district and taluk headquarters) and tertiary

care hospitals (located in district and state headquarters or those that are teaching hospitals).

_____________________________________________

2.http:www.indianhealthcare.in/index.php?option=com_content&view=article&catid=131&id=168%3AIndian+H

ealthcare:+The+Growth+Story



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History:

The art of Health Care in India can be traced back nearly 3500 years. From the early days of Indian history the

Ayurvedic tradition of medicine has been practiced. During the rule of Emperor Ashoka Maurya (third century

B.C.), schools of learning in the healing arts were created. Many valuable herbs and medicinal combinations were

created. Even today many of these continue to be used. During his reign there is evidence that Emperor Ashoka

was the first leader in world history to attempt to give health care to all of his citizens, thus it was the India of antiquity which was the first state to give its citizens national health care.

Healthcare Infrastructure:

The Indian healthcare industry is seen to be growing at a rapid pace and is expected to become a US$280 billion

industry by 2020. The Indian healthcare market was estimated at US$35 billion in 2007 and is expected to reach

over US$70 billion by 2012 and US$145 billion by 20173. According to the Investment Commission of India the

healthcare sector has experienced phenomenal growth of 12 percent per annum in the last 4 years 4. Rising income

levels and a growing elderly population are all factors that are driving this growth. In addition, changing

demographics, disease profiles and the shift from chronic to lifestyle diseases in the country has led to increased

spending on healthcare delivery5.

Even so, the vast majority of the country suffers from a poor standard of healthcare infrastructure which has not

kept up with the growing economy. Despite having centers of excellence in healthcare delivery, these facilities are

limited and are inadequate in meeting the current healthcare demands. Nearly one million Indians die every year

due to inadequate healthcare facilities and 700 million people have no access to specialist care and 80% of

specialists live in urban areas6

________________________________

3. http://www.ibef.org/industry/healthcare.aspx

4 .http://cii.in/menu_content.php?menu_id=238

5. http://knowledge.wharton.upenn.edu/india/article.cfm?articleid=4277

6. The Times of India.

http://economictimes.indiatimes.com/Healthcare/Lacking_healthcare_a_million_Indians_die_every_year_Oxford

_University/articleshow/4066183.cms.





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Expenditure:

In the mid-1990s, health spending amounted to 6% of GDP, one of the highest levels among developing

nations. The established per capita spending is around Rs 320 per year with the major input from private

households (75%). State governments contribute 15.2%, the central government 5.2%, third-party insurance

and employers 3.3%, and municipal government and foreign donors about 1.3, according to a 1995 World

Bank study. Of these proportions, 58.7% goes toward primary health care (curative, preventive, and

promotive) and 38.8% is spent on secondary and tertiary inpatient care. The rest goes for non-service costs.

The Fifth (1974 – 78) and Sixth Five-Year Plans and (1980 – 84) included programs to assist delivery of

preventive medicine and improve the health status of the rural population. Supplemental nutrition programs

and increasing the supply of safe drinking water were high priorities. The sixth plan aimed at training more

community health workers and increasing efforts to control communicable diseases. There were also effortsto improve regional imbalances in the distribution of health care resources.

The Seventh Five-Year Plan (1985 – 89) budgeted Rs 33.9 billion for health, an amount roughly double the outlay

of the sixth plan. Health spending as a portion of total plan outlays, however, had declined over the years since the

first plan in 1951, from a high of 3.3% of the total plan spending in FY 1951-55 to 1.9% of the total for the

seventh plan. Mid-way through the Eighth Five-Year Plan (1992 – 96), however, health and family welfare was

budgeted at Rs 20 billion, or 4.3% of the total plan spending for FY 1994, with an additional Rs 3.6 billion in the

non-plan budget.

Health insurance:

The majority of the Indian population is unable to access high quality healthcare provided by private players

as a result of high costs. Many are now looking towards insurance companies for providing alternative

financing options so that they too may seek better quality healthcare. The opportunity remains huge forinsurance providers entering into the Indian healthcare market since 75% of expenditure on healthcare in

India is still being met by „out-of- pocket‟ consumers12.

_________________________________

12. http://www.technopak.com/tkc/index.asp?ol=8



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Even though only 10% of the Indian population today has health insurance coverage, this industry is

expected to face tremendous growth over the next few years as a result of several private players that have

entered into the market. Health insurance coverage among urban, middle- and upper-class Indians, however,

is significantly higher and stands at approximately 50%13.

The Insurance Regulatory and Development Authority (IRDA) is the governing body responsible for

promoting insurance business and introducing insurance regulations in India14. The share of public sector

companies in health insurance premiums was 76% and that of private sector companies was 24% for the

period 2005-06. Health insurance premiums collected over 2005-06 registered a growth of 35% over the

previous year15. In 2001 the IRDA introduced provisions for Third Party Administrators (TPAs) to support

the administration and management of health insurance products offered by insurance companies. TPAs are

facilitators in the coordination process between the health insurance provider and the hospital. Currently

there are 27 TPAs registered under the IRDA16.

Health insurance has a way of increasing accessibility to quality healthcare delivery especially for private

healthcare providers for whom high cost remains a barrier. In order to encourage foreign health insurers to enter

the Indian market the government has recently proposed to raise the foreign direct investment (FDI) limit in

insurance from 26% to 49%17. Increasing health insurance penetration and ensuring affordable premium rates are

necessary to drive the health insurance market in India

__________________________________

13. "Healthcare in India". Boston Analytics.

http://www.bostonanalytics.com/india_watch/Healthcare%20in%20India%20Executive%20Summary.pdf.

14. http://www.irdaindia.org/

15. http://www.technopak.com/tkc/index.asp?ol=8

16. http://www.indianhealthcare.in/index.php?option=com_content&view=article&catid=121&id=170

17.http://www.indianhealthcare.in/index.php?option=com_content&view=article&catid=39:&id=330:MALVIND

ER,+SHIVINDER+PLAN+TO+ENTER+HEALTH+INSURANCE+BIZ+&Itemid=



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CHAPTER-3

IMPORTANCE HEALTH INSURANCE

Health Insurance is expected to play a critical role in ensuring healthcare access to people in India. The level

of penetration of Health Insurance in India has been on a steady rise; however, it is clear that there is still a

long way to go from single digit access figures to meeting global penetration levels.

By observing the following lines we can understand importance of Health Insurance

Health insurance protects individual from the risk of medical bills of health care. Without health

insurance people may not be able to afford high cost of medical services

Cashless hospitalization facility is provided by the Health insurance which is very useful to the

people who had no money in hand.

Health insurance also useful to protect the family members from unexpected disease conditions by

taking floater policy for total family.

Health Insurance policies have tax benefits under 80D of income tax act.

Combi product is an interesting concept and has got potential which gives both life and Health cover. Today, a

traditional life insurance product does not cover the cost of a healthcare incident. Similarly, a traditional

healthcare product takes care of healthcare financing to a certain extent, but does not take care of the financial

needs in the event of loss of life. Here, the regulator has given an opportunity to those who wish to buy a product

that combines the merits of two products into one.

Health policies provide health cover from Rs 30,000 to Rs 20 lakh. This is the highest limit offered in the

industry. In an Rs 20-lakh cover, Rs 10 lakh will be for the indemnity cover and a Rs 10-lakh worth critical

illness rider can be attached to it. So, people are welcome to take any amount of cover they feel is suitable for

them. All of customers were interested in buying health insurance because they know healthcare costs are

rising and insurance is a smart way to take care of unforeseen events. But they are confused on what to buy

and from whom. They do not know what an insurance policy cover provides and what it does not.

Today some of the products cover maternity, dental costs, pharmacy purchases; preventive measures all of

this, of course, and comes at a cost. But at least companies are providing it.



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CHAPTER-4

OVERVIEW OF HEALTH INSURANCE MARKET IN INDIA

Some facts on Health Expenditure in India:

The magnitude of health expenditure in India for the year 2001-02 was about 4.8% of the GDP at current

market prices. Over three-fourths of all health spending is private spending (70% of total is by households)

Less than 15 percent of people in India have some form of health insurance coverage. More than 40 percent

of the people hospitalized had to borrow money / sell assets to cover expenses. A quarter of those

hospitalized fall below the poverty line because of high costs. Medical care is one of the 3 main causes of

impoverishment in the country. Recent NSSO data (60th round) indicates a large share of consumption

expenditure is on health (13% in rural, 10% in urban)

Current Status in India: Growth Trends

Health insurance has been the fastest growing segment in the non-life insurance industry in India over the last

few years Commercial health insurance (i.e. purchased from insurance companies) constituted only 0.7% of

this expenditure in 2001-02 and barely covered 1% of the population. By the end of 2008-09, healthInsurance premium would have grown about ten-fold from a level of Rs. 675 crores in 2001-02, in just 7

years. It grew 60% during 2007-08 to command a market (in non-life companies) of over Rs 5100 18 crores as

against Rs 3200 crores in 2006-07. During April-September 2008 (latest provisional figures), it again shows

47% growth over the corresponding period in the previous year and business in Apr-Sep „08 is higher than

entire FY 2006-07. It is also emerging as an increasingly significant line of business for life insurance

companies, and all the large life insurance companies now have products in the health insurance space, the

most conspicuous ones among these having been launched in the last 12 months itself.

_____________________________________

18. IRDA Journal and IRDA Annual Reports



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Some factors driving growth:

Increasing awareness of Health Insurance, especially in the formal sector/ employed groups. Rising

healthcare costs have increased need for health insurance. Government schemes like RSBY and Aarogyasree,

in terms of premium and even more so in lives covered. Detariffing of the general insurance industry (which

has increased emphasis and efforts by insurance companies towards health insurance and other personal lines

of business) Rationalization of premium rates (e.g. trend of upward revision in respect of Group Health

policies).

Reach and Persons Covered:

Overall, still low coverage for risk protection against major health related expenditure in the country.

Insurance and other organized forms of payment for health services, including ESIS, CGHS and other such

employer schemes, presently cover <15% of all people in the country. (Membership:47 million under ESIS, 4

million under CGHS, and upwards of 100 million under government-sponsored, group and individual

commercial health insurance, plus coverage under schemes of Defence, Railways, PSUs- esp. steel and coal

etc.) From a figure of 25 million persons in 2006-07, the present figures rose sharply largely on account of

large scale government sponsored health insurance programmes, prominent being the Rajiv Aarogyasri

scheme in AP (covers 18 million households) and the centrally-sponsored Rashtriya Swasthya Bima Yojana

(RSBY) (over 1 million households corresponding to over 3 million persons enrolled as of Dec 2008)

Insurance currently pays less than one-tenth of all hospitalization expenditure in the country





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5.1 MEDICLAIM POLICY (INDIVIDUAL):

The policy provides for reimbursement of Hospitalization/ Domiciliary hospitalization expenses for

illness / disease suffered or accidental injury sustained under the policy period.

The policy pays for expenses incurred under the following headings

1. Room, Boarding Expenses in hospital / nursing home.

2. Nursing expenses

3. Surgeon, anaesthetist, Medical practitioner, consultants, specialist fees.

4. Anaesthetist, blood, oxygen, operation theatre charges, surgical appliances, Medicines and drugs,

diagnostic materials, and X-ray, Dialysis, chemotherapy, radiotherapy, cost of pacemaker, artificial

limbs and cost of organs and similar expenses.

5. The liability in respect of all claims admitted during the period of insurance shall not exceed the sum

insured for the person as mentioned in the policy

6. The company will pay through TPA named in the schedule policy to insured person reasonable and

necessary expenses incurred in respect of medical or surgical treatment. Reimbursement is allowed

only when treatment is taken in a hospital or nursing which satisfies the criteria specified in the

schedule.

7. Expenses on hospitalization for minimum period of 24 hours are admissible. However this time limit

is not applied to specific treatment .i.e. dialysis, chemotherapy.

8. Relevant medical expenses incurred during the period up to 30 days prior to and period of 60 days

after hospitalization are treated as the part of the claim.

Domiciliary hospitalization benefit:

This means medical treatment for a period exceeding three days for such illness / injury in the normal course

would require treatment at the hospital or nursing home but actually taken whilst confined at home in India

under any of the following circumstances namely:-

1. The condition of the patient is such that he / she cannot be removed to the hospital / nursing home or

2. The patient cannot be removed to hospital / nursing home for lack of accommodation there in.

However this benefit does not cover:-i. Expense incurred for pre and post hospital treatment and

ii. Expense incurred for treatment for any of the following diseases

1. Asthma

2. Bronchitis



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3. Chronic nephritis

4. Diarrhoea and all type of dysenteries including gastro enteritis

5. Diabetes Mellitus and inspidus

6. Epilepsy

7. Hypertension

8. Influenza, cough and cold

9. All psychiatric or psychosomatic disorders

10. Pyrexia of unknown origin for less than 10 days

11. Tonsillitis, and upper respiratory tract infection including laryngitis and pharyngitis

12. Arthritis, gout and rheumatism.

Under the policy any one illness means continuous period of illness and it includes relapse within 45 days

from the day of last consultation with hospital or nursing home where treatment may have been taken.

Occurrence of same illness after a lapse of 45 days will be considered as fresh illness for purpose this policy.

Exclusions

No claim is payable in respect of the following

1. All diseases / injuries which are pre-existing when the cover incepts for the first time.

2. Any disease other than those stated in the 3rd point contracted by the insured person during the first

thirty 30 days from the commencement date of policy. This condition shall not however apply in the

case of insured person having been covered under this scheme or group insurance scheme with any of

the Indian insurance companies for a continuous period of preceding 12 months without break.

3. During the first year of the operation of the policy the expenses on treatment of diseases such as

cataract, benign prostatic hypertrophy, hysterectomy for menorrhagia or fibromyoma hernia,

hydrocele, congenital internal disease, fistula in anus, piles , sinusitis and related disorders. If these

are pre-existing at the time of proposal they will not be covered even the subsequent period of

renewal.

4. Circumcision unless necessary for the treatment of disease not excluded here under or as may be

necessitated due to an accident, vaccination or inoculation or change of life or cosmetic or aesthetictreatment of any description plastic surgery other than as may be necessitated due to an accident or as

a part of illness.

5. Cost of spectacles and contact lenses and hearing aids. Dental treatment or surgery of any kind unless

requiring hospitalization



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6. Convalescence, general debility, run down condition or rest cure, congenital external disease defects

or anomalies sterility and venereal disease intentional self-injury and use of intoxicating drugs or

alcohol.

7. Various conditions as commonly referred to AIDS. Charges incurred at hospital or nursing home for

diagnostic, X-ray or laboratory examination or other diagnostic studies not consistence with positive

of any ailment for which confinement is required at a hospital or nursing home or at home under

domiciliary hospitalization defined.

8. Expenses on vitamins and tonics unless part of treatment. Treatment arising from pregnancy or

childbirth. Naturopathy treatment.

Conditions:

1. Notice of any claim with full particulars shall be sent to the TPA immediately and within 24 hours of

emergency hospitalization / domiciliary hospitalization

2. All claim documents must be filed with the TPA within 7 days from the date of discharge from the

hospital or the date of completion of post hospitalization treatment.

3. Any medical Practitioner authorized by the TPA / company shall be allowed to examine the insured

person in case of alleged injury or disease as may be reasonably required by the company.

4. All treatment shall have n\been taken in India and all claims are payable in Indian currency.

Cumulative bonus:

The sum insured is increased by 5 % for each claim free year of insurance subject to maximum accumulation

of 10 years. In the event of claim, the increased percentage will be reduced to 10 % of the sum insured at the

next renewal but the basic sum insured will remain the same.

Cost of health check-up:

The insured shall be entitled to reimbursement of medical check-up once in ever four underwriting years

subject to no claim preferred during this period. The cost shall not exceed 1% of the average sum insured

during the block of 4 years.

Sum insured and premium:The sum insured is decided by the insured. The sum insured is usually available from 15,000 to 5,

00,000/-. Liability of domiciliary hospitalization is limited to percentage of the sum insured. The premium

varies according to the sum insured and age limits. Tax benefit is available under section 80D of the Income

tax act.



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Age limit:

The insurance is available to persons between ages of 5 years to 80 years. Children between the age of

3months and 5 years of age can be covered provided one or both parents are covered simultaneously.

Family discount:

A discount in the total premium is allowed to a family comprising the insure or any one or more of the

following

1. Spouse

2. Dependent children

3. Dependent parents.

5.2 MEDICLAIM POLICY (GROUP):

The Group Mediclaim is available to any group / Association / institution /Corporate body provided it

has central administration point and subject to minimum number of persons to be covered.

The group shall fall clearly under the same categories as specified for the personal accident policy.

The group policy is issued in the name of the group / Association / institution / corporate body (called

insured) with a schedule of the names of the members including his / her eligible family members

(called insured persons) forming the part of the policy. The coverage under the policy is same as

under individual Mediclaim policy with the following differences

1. Cumulative bonus and health check-up expenses are not payable

2. Group discount in the premium is available

3. Renewal premium is subject to Bonus / Malus clause

4. Maternity benefit extension is available at extra premium.

Group discount:

The group discount is allowed according to scale depend upon the total number of insured persons

covered under the group policy.

Bonus /Malus:Low claim ratio discount is allowed on the total premium at renewal only depending upon the incurred

claims ratio for the entire group. On the same basis incurred claim ratio, loading is applied to the renewal

premium for adverse claims experience.



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Maternity expenses benefit extension:

This is an optional cover which is available on the loading of the total; basic premium for all the insured

persons under the policy. The maximum benefit allowable is up to Rs.50000/-.or the sum insured opted

by the member of the group, whichever is lower.

The special conditions applicable to this extension are

a. These benefits are admissible only if the expenses are incurred in hospital or nursing home as in

inpatients in India.

b. A waiting period of 9 months is applicable for payment of any claim relating to normal delivery or

caesarean section or abdominal operation for extra uterine pregnancy. The waiting period may be

relaxed only in case of delivery, miscarriage or abortion induced by accident or other medical

emergency.

c. Claim in respect of deliver is considered for first two children will be considered in respect of any one

insured person. Those insured persons who are having two or more living children will not be eligible

for this benefit.

d. Expenses incurred in connection with voluntary medical termination of pregnancy during the first 12

weeks from the date of conception are not covered.

e. Pre-natal and post nat5al expenses are not covered unless admitted in hospital or nursing home

And treatment is taken there.

Details of the insured person:

1. The insured is required to furnish a complete list of insured persons in the prescribed format

according to sum insured.

2. Any additions and deletions during the currency of the policy should be intimated to the company

in the same format. However such additions and deletions will be incorporated in the policy from the

first day of the following month subject to pro rata premium adjustment.

3. No change of sum insured for the any person will be permitted during the currency of the policy.no

refund of premium is allowed for deletion of insured person if he or she has recovered claim under

the policy.

5.3. CANCER POLICY (CPAA): This policy is granted to the members of the cancer patient‟s aid association (CPAA). The insured by the

virtue of being the member of CPAA has to submit a proposal form with a declaration that he is in good

health and he is not suffering from cancer. He has to undergo medical check-up and certification to that effect

has to be made by CPAA in the proposal form. The proposal form and the certification form part of the



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contract of insurance.

The premium shall be paid by the insured to CPA as a part of membership fee and this also applies as a

condition to the renewal of the policy. Group policies are also available with discount in the premium. The

policy will pay to the medical / surgical / hospitalization /diagnostic expenses actually and necessarily

incurred but not exceeding the sum insured. Only allopathic mode of treatment is covered.

Coverage:

1. If the insured during currency of the policy suffers from cancer, the policy will pay to the insured

medical / surgical / hospitalization and diagnostic expenses actually and necessarily incurred but not

exceeding the sum insured. Only allopathic treatment is covered.

2. The sum insured is increased by 5 % for each claim free year of insurance subject to maximum

accumulation of 10 years. This cumulative bonus is lost if the policy is not renewed within 30 days

after expiry.

Exclusions: No claim is payable

1. If the insured contracts cancer within a period of 30 days from the date of becoming member of the

CPAA.

2. Unless the diagnostic investigation reveals positive presence of cancer.

3. By reason of the contact of the insured with radiation or radioactive from any source other than

diagnostic or therapeutic source.

4. If the insured ceases to the member of the CPAA

5.3 CRITICAL ILLNESS INSURANCE:

The policy is designed to pay the sum insured if during the policy period the insured is found to have a

critical illness contracted during the period of insurance, and survives such critical illness for at least 30 days

from the date of its discovery.

A critical illness shall mean one of the following suffered or undertaken by the insured as long as it is shown

in the schedule to be an operative event

1. cancer

2. Coronary artery By Pass graft Surgery

3. Myocardial infarction ( Heart attack)



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4. End stage renal Failure

5. Major Organ transplant

6. Stroke

7. Paralysis

8. Heart Valve Replacement Surgery

9. End stage liver disease

10. Loss of limbs

11. Loss of speeches

12. Major burns

13. Coma

14. Alzheimer‟s disease

15. Blindness

16. Parkinson‟s Disease

17. Deafness

18. Multiple sclerosis

Exclusions

The company shall not liable or make any payment for any claim directly or indirectly caused by, based on;

arising out of or howsoever attributable any of the following.

1. Any critical illness existing or for which the insured sought or received treatment prior to :

a. The inception date of the first policy of a series of critical illness policies taken by the insured

from the company without any break where this insurance known in the schedule to be annual

contract or longer term contract.

b. The inception date of this policy where this insurance is shown in the schedule to be annual

contract and either

i. This the insured‟s first critical insurance policy taken from the company, or

ii. There has break between this critical illness policy being taken and an earlier critical

illness policy expired.

2. Any critical illness discovered or discoverable within 90 days of inception date of this policy, but thisexclusion shall not apply to the second or subsequent policy taken by the insured from the company

without any break.

3. Congenital external illness or defects or anomalies, intentional self- injury and the use or misuse of

intoxication liquor or drugs.



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4. Pregnancy and childbirth. conditions commonly referred to as AIDS

5.3 OVERSEAS MEDICAL POLICY

This policy provides for payment of medical expenses in respect of illness suffered or accident sustained by

Indian residents during their overseas trips for a specified purpose

Eligibility: Indian Residents undertaking bonafide trips abroad for:

1. Business and official purposes

2. Holiday purpose

3. Employment

4. Studies

5. Accompanying spouse and the children of the person who is going abroad will be treated as going

under holiday travel

6. Foreign nationals working in India for Indian employers of MNCs getting their salaries in the Indian

rupees, covering their official visits abroad provided they are undertaken on behalf of their

employers.

Age Limit:

1. For Adults up to 70 years, cover beyond 70 years is granted at extra premium.

2. For children above 6 years, children between the ages of 6 months to are covered by excluding

certain specific children diseases such as mumps measles etc.

Policy coverage:

Insured Person is that person named in the overseas policy schedule, for whom the appropriate premium has

been paid.

Period of insurance:

The insurance is valid from the first day of insurance or date and time departure from India whichever is later

and expires on the last date of the number of days specified in the policy schedule or on return to India

whichever is earlier. Extension of the period of insurance is automatic for the period not exceeding 7days,

without extra charge.Local Medical Advisors:

Name and address of an overseas independent entity which provide emergency assistance and claims

administration services abroad are specified in the policy.





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iii. Routine physical examination or any other examination where there is no objective

indication of impairment of normal death.

2. The insurance will not cover pregnancy of the insured person including resulting childbirth, etc.

miscarriage, abortion or complication of any of these.

Section B- personal accident

This insurance will pay the limit as shown in the schedule if the insured person sustains bodily injury within

12 months of date of injury is the sole and direct cause of the death. Permanent total disablement loss of eye

(s) or limb(s).Not more than US $ 2,000 is payable in the respect of death if the insured person‟s age is under

16.

Section C – Loss of checked baggage

The insurance will pay up to the limit of cover shown in the schedule in the event of the insured person

suffering a total loss of baggage that has been checked by an international airline for an international flight.

No claim will be paid for valuables such as photographic audio, computer, telecommunication and electrical

equipment & telescopes and binoculars spectacles, sunglasses, antiques, jewellery, furs and articles made of

precious stones and metals. Any recover from the a carrier or any airline shall become the property of

insurers.

Section D – Delayed of checked baggage

The insurance will pay up to the limit of cover shown in the schedule for the necessary emergency purchase

of replace items in the event that insured person suffers a delay of more than 12 hours from the scheduled

arrival time at the destination for delivery of baggage that has been checked by an international airline for an

international outbound flight from India. A non- delivery certificate from the airline and the proof of

purchase must be submitted in support of any claim under this section.

Loss of passport:

This insurance will pay up to the limit of cover shown in the schedule for the reimbursement of actual

expenses necessarily and reasonably incurred by the insured person in connection with obtaining emergency

travel documents in lieu of lost passport, outside India.

No Claim will be paid that is less than the deductible stated in the schedule. The deductible is apply to each

insured event and shall be borne by the insured person.



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No claim shall be paid for

a. Loss or damage to passport due to delay, or from confiscation or detention by customs police or other

authority.

b. Theft which is not reported to police authority and an official report obtained.

Section F - Personal Liability:

This insurance will pay up to the limit of cover shown in the schedule if the insured person in his or her

private capacity becomes legally liable to pay for accidental bodily injury to third parties or accidental

damage to third party property, arising from an accident during the covered trip. Some exclusions are as

follows:

No claim shall be paid

a. For less than the deductible

b. Arising out of the animals belonging to the insured person, or pursuit of trade, profession,

occupation etc.

General Exclusions Applicable to all sections (some examples)

No claim will be paid

a. Where the insured person

1. is travelling against the advice of a physician; or

2. is on waiting list for specified medical treatment: or

3. is travelling for the purpose of obtaining medical treatment: or

4. has received a terminal prognosis for a medical condition.

b. suicide, attempted suicide, venereal disease or abuse of drugs or alcoholic drinks or HIV related illness.

c. In respect of medical services with in India (unless when specifically provided)

d. Arising from the insured taking part in navel, military or air force operations.

e. Arising from aviation except where the insured flies as a passenger in an aircraft properly licenced to

carry passengers.

f. Arising from participation in professional sports events or other hazardous sports.

General Conditions Applicable to all sections (some examples)a. i. The policy will be valid only if insured journey commences within 14 days of the first day of

insurance as indicated in the policy schedule.

ii. Cancellation of the policy may be done ONLY in cases where a journey is not undertaken and only

on production of the insured person‟s PASSPORT as a proof that the journey has not been undertaken.



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Such cancellation will be subject to deduction of cancellation charge by the underwriters as applicable.

b. In the event of any occurrence likely to give rise to a claim under this insurance, the insured person,

or his representative must notify local medical advisers immediately.

For non-emergency claims local medical advisors should be contacted upon return to the republic of

India and a claim form obtained. This document, together with invoices, travel documents and any

other relevant details must be sent to them clearly stating under which section of the policy a claim is

being made.

c. This insurance does not operate beyond a period of 180 days continuous absence from India unless

specifically agreed by insurers.

d. Pre-existing exclusion: the policy is not designed to provide indemnity in respect of medical services,

the need for which arises out of a pre-existing condition

e. The laws of the republic of India shall govern the validity interpretation etc. of the policy.

f. Any dispute under the policy shall be subject to arbitration as per the provisions of the Indian

arbitration and conciliation act, 1996.

g. No sum payable under the policy shall carry interest.

Premium:

The premium depends upon age, duration of stay and the countries visited.

5.6. CORPORATE FREQUENT TRAVELLERS:

This is an annual policy granted to officials of the companies registered under the companies act, who are

regularly travelling abroad. This policy is available to partners of registered firms.

The salient features of the endorsement attached to the policy are:

a. The insurance is valid in respect of trips undertaken during 12 months following the date of purchase as

stated in the schedule-subject to the duration of any trip not exceeding 60 days.

b. In the event that the insured person is travelling outside India on the last day of insurance the cover shall

extend to include duration of trip until his return to India within 59 days of the expiry date.

c. No cover is available for persons over the age of 70.d. The cover granted is always subject to the insured person advising the insurance company any material

change in health condition.

e. Policy to be issued individuals only.



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5.7. CORPORATE GROUP OMP (DECLARATION BASIS)

This is a new scheme designed for corporates who regularly send their employees abroad for business,

training, project work etc. The policy is granted by charging an advance deposit premium for a specified

number of days and the insured is required is submit details of the persons who go abroad. Such declarations

have to be given prior to departure from India. Calculation of actual premium on the basis of number of

days and necessary replenishment is done as and when required. The policy operates as per endorsement

attached to overseas Medical policy.

1. This insurance is valid in respect of trips undertaken by the employees of the insured who are in good

health and for whom separate certificates of insurance have been issued as authorised, during 12 months

following the date of purchase as stated in the schedule.

2. In case of a certificate where period of insurance cover goes beyond the expiry date of this policy the

insured person named therein, shall continue to be covered for period of insurance stated in the said

certificate applying the same terms and conditions mentioned in the insurance policy.

3. It is understood and agreed that the person covered under this endorsement was not more than 70 years

of age at the inception of the period of insurance.

a .It is understood and agreed that the cover granted under this endorsement is subject to medical reports

submitted by the insured person who is above the age of 60 years at the time of commencement of

journey, or who has been treated for any illness/injury during the 12 months preceding the journey.

b. It is understood and agreed that the cover granted under this endorsement is always subject to the

insured person advising the insurance company any material change in his / her health condition.

c. No certificate will be issued for a period not exceeding 180 days.

d. Premium under this policy is adjusted on declaration basis, subject to a minimum retention of

500days premium.

Premium:

The premium is charged on per day basis and varies according to the type of plan, countries visited.

5.8 EMPLOYMENT AND STUDY POLICY:

The policy is designed for Indian citizens temporarily posted abroad in a sedentary non manual work or

students prosecuting studies or engaging research activities in abroad. The new scheme is on a world-wide

basis, including USA/ Canada.



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Sub-section A:

Medical expenses incurred in respect of disease / injury contracted/ sustained during the policy period.

i. Under the policy

ii. 52 weeks after the onset of injury / sickness.

iii. 12 weeks after the expiration date of the insurance.

Sub-section B

If the insured person is evacuated to India the insurers will pay medical expenses in India, as provided under

sub-section A above in addition but within the overall limit of US $ 5,00,00/-.

Sub-section C

Repatriation and alternative expenses: In the event of the death of an insured person, the insurer will pay

the actual expenses for preparation and transportation to India of the remains of the insured person or the

funeral expenses incurred in the country of posting, not exceeding US $ 8,000 in total

Sub-section D

Medical emergency reunion expenses up to US $ 5,000/- in all when, as a result of covered injury or covered

sickness insure person is hospitalized and it is agreed by all parties that the insured person medically

evacuated to India as soon as possible insurer will pay upon the recommendation and prior approval of the

claims administrator the following expenses incurred in respect of travel by mother or father or guardian or

spouse.

a. The cost of an Economy air ticket one person from India to the airport serving the area where the

insured person is hospitalized and return to India.

b. Reasonable travel and accommodation expenses incurred in relation to emergency Reunion. The

proposal form, underwriting procedures, policy exclusions etc. are more or less similar to overseas

medical scheme for business or holiday.

c. The scheme may include add on covers as follows:

1. Loss of checked baggage ( limit US $1000)

2. Delayed baggage (limit of US $100) (outbound flight)



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CHAPTER-6

COMPARISION DIFFERENT TYPES OF HEALTH INSURANCE PRODUCTS OFFERED BY

INIAN INSURANCE COMPANIES

Health insurance in India was first marketed by non-life insurers as a standardized annual indemnity product,

Mediclaim, in 1986. The product variety available has increased substantially now, though the indemnity-

based annual contract continues to be the form which predominates. In the current scenario of India in total

24 General insurance companies are with authority and was doing business.

Out of 24 only 18 companies were offering health insurance products. Out of that 18 companies 4 are public

companies and remain 14 are private companies. The types of products in common offered by public

companies and private companies are classified in chapter 5.

Public companies offered their products in different headings as follows

1. Personal e.g. New India, national Insurance.

2. social e.g. New India

3. popular e.g. oriental bank of commerce

4. health e.g. united India

5. Miscellaneous. E.g. United India

Public companies are products mainly concerned about social security of poor people i.e. they were

providing health insurance to poorer section of people with a minimum premium e.g. universal health

insurance scheme by oriental insurance, Jan arogya Bima policy by United India insurance.

The four public companies were specially offering products to customers and employees of different banks

e.g. National insurance company offering products to Bank of India, Bank of Baroda and UCO bank. They

are BOI National Swasthya policy and UCO Medi + Care Bima Policy. The others areas were focussed by

public companies are senior citizens, students and individual and group policies. One of senior citizens

products is varshitha Mediclaim policy by national insurance company. The products related to students are

VIDYARTHI- Mediclaim and overseas Mediclaim policy for employment and studies offered by NationalInsurance Company and oriental insurance company respectively. Critical Insurance Products offered by

oriental and national insurance companies covers only a list of 6 diseases.



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Out of 14 private companies 3 companies were standalone Health Insurance Companies. This indicates the

aggressive intention of private companies to capture the health insurance market of India. When compare

with public companies these were not providing social security polices and products to different banks

customers and employees. Private companies offering wide range of coverage products with low premium

when compared with public companies.

Private companies offered their products in different headings as follows

1. Health

I. Individual

II. Family

2. Critical illness

3. Travel

“Maxima” a product offer to both individual and family which is a plan with unique out-patient features to take

care of your regular illnesses and little niggles such as Doctor Consultations, Pharmacy, and Expenses

Diagnostics , Specialist Services, Health Check-ups and Pre-existing illnesses under OPD Benefits Etc.

Private companies providing cover to day care procedures which need not require 24 hours hospitalization such as

cost of radiation, chemotherapy and dialysis e.g. ICICI LOMBARD family floater, MAX BUPA Heart Beat silver.it is

great selling point for private companies.

Smart care critical health insurance policy offered by Bharathi-AXA Company has wide range cover about 20

critical care diseases. When compared with public companies and other private companies this is an excellent

product because the others are only covering about 6-10 diseases only.

Star shri individual and family care which is an exclusive product which covers both life and health of

individuals and family offered by Star Health and Allied insurance Co, Ltd., and Shriram Life Insurance Co,

Ltd. Star Shri Individual Care Insurance is a product that provides for regular hospitalization benefits like any

other medical insurance policy under section 1. Moreover, this product also provides for payment of lump-

sum in the event of death, including death due to natural causes, under section 2. Coverage under Section 1 is

provided by Star Health and Allied Insurance Company Limited and Coverage under Section 2 is provided

by Shriram Life Insurance Company Limited.



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Star Unique Health Insurance is a health policy with dual benefit - it covers provides for hospitalization

benefits as well as cover for Pre-Existing Diseases after a waiting period of 11 months. The normal waiting

period for covering Pre-Existing Diseases is 48 months of continuous insurance with the Company. This

waiting period is now reduced to 11 months. Persons who are perceived as high risk like Hypertensive or

diabetic can take this insurance.

Star unique wedding gift policy which offers protection in adversity and supports at times of joy. The policy

offers basic health cover for the couple on a floater basis. In addition it provides for Child del ivery expenses -

whether for Normal Delivery or for delivery by Caesarean Section up to the limits provided. A waiting

period of 36 months applies for availing this benefit. Minimum qualifying age is 18 years and cover is

available up-to 40 years. Renewable up-to 45 years. Thereafter cover will be given under any other health

cover of the Company with continuity of benefits. Couple already with a child can be covered. Policy isavailable for a one year, two year and four year term. Entire premium payable in advance. Two sum insured

options are available - namely Rs 300000 and Rs500000/- each with different benefits.

Broadly the policy offers cover four different heads:

Hospitalization cover

Child Delivery Expenses

Cover for New born baby

Lump-sum payment if the New Born is a Down's baby or is suffering from Cerebral Palsy

Cost of test for detection of foetal abnormality.



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CHAPTER-7

EPILOGUE

The topic is related to Health Insurance products. Therefore it gives the picture of various types of health

insurance products and comparison of various health insurance products offered by various Indian Insurance

companies. Within the personal lines of business also, the predominant volumes and growth are being seen in

two areas- motor and health, of which the motor insurance segment more or less follows the fortunes of the

automobile industry. Thus, additional motor insurance business finally depends on the production patterns of

automobiles. On the other hand, the promising area where insurers can build up volumes and gain new

business through their own additional efforts, is health insurance

The insurance companies have indeed risen to this challenge and have taken efforts, more than ever before, to

grow the health insurance market. The demand for health insurance covers has seen a healthy increase, andtoday the sector is the fastest growing segment in the non-life insurance industry in India, which grew at over

40% last year. It is also emerging as an increasingly significant line of business for life insurance companies.

During the last five years, the premium from health insurance products in non-life companies has grown from

675 crores in 2001-02 to Rs 3200 crores in 2006-07, almost 5 times its level 5 years back .

Some recent estimates by reinsurers and by consulting firms suggest that health insurance is likely to grow

rapidly, cover 20% of the population and constitute 12% of the total health market of the country, or over Rs

30,000 crores by 2015, which implies a ten-fold increase over the next 8 years. While the magnitude of such

growth in health insurance is a matter of estimation, there is no doubt that there is tremendous potential for

development of health insurance.

Thus, there can be no dou bt that health insurance is a „need‟, that requires to be addressed. This is where

there is a role to develop more products, to address needs of specific target groups, and at the same time, tobuild awareness regarding health insurance and its potential to protect from such unforeseen health

expenditure. Thus, a lot more needs to be done by the trade chambers, the insurance industry, the health

providers and also the IRDA to develop the health insurance sector.



Documents

202-Personal Insurance Final