Roop Major Research Project

8/8/2019 Roop Major Research Project

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MAJOR RESEARCHPROJECT

ON

STUDY OF EXISTING SYSTEM IN HEALTH INSURANCE

Submitted in the partial fulfillment of the attainment of Bachelor

Degree of Hospital Administration

DEVI AHILYA UNIVERSITY

INDORE, MADHYA PRADESH

Submitted to - Submitted by-

Mrs. Nisha Bano Siddiqui Roop Kumar Dehariya

Lecturer BBA (HA), V1 Sem

IMS, DAVV IMS,DAVV

INSTITUTE OF MANAGEMENT STUDIES
http://www.dauniv.ac.in/


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DEVI AHILYA VISHVAVIDHYALAYA, INDORE

DECLARATION

I undersigned here by declare that, I the student of

Bachelor of Hospital Administration has done the major research project on

STUDY OF EXISTING SYSTEM IN HEALTH INSURANCE & the

project is based on my own authentic work.

The work done by the other, if referred has been properly acknowledge.

Date: ROOP KUMAR DEHARIYA

BBA (H.A.) 6th sem

Place: IMS, DAVV Indore

BBA (HA), 6th Seem


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BBA (HA), III Semester

CERTIFICATE

TO WHOMSOEVER IT MAY CONCERN

This is to certify that, Roop kumar Dehariya, student of B.B.A. (H.A.) 6TH Semester

from Institute of Management Studies has done the major research project on the

topic-

STUDY OF EXISTING SYSTEM IN HEALTH INSURANCE


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His project work is original and up to my satisfaction.

I wish him all the best for his future.

Project guide:-

Mrs. Nisha Bano Siddiqui,

Lecturer,

IMS DAVV,

Indore,

ANOWLEDGEMENT

There are always many people behind the completion of any project. This project is

also completed with cooperation, suggestion and blessing of many people. Our

intellectual debts in preparing this project are large an unaccountable.

I am extremely grateful to

ICICI Prudential Life Insurance Corp.

Tata AIG Life Insurance of India.

ING Vysya Life Insurance of India.


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I acknowledge with gratitude, the help I received from Mrs Nisha Bano Siddiqui,

Lecturer, and IMS who gives me her valuable time and help me to understand

things in the department.

Finally I would like to thank all those who directly or indirectly help me in

completing this project.

Roop kumar Dehariya

BBA (HA) VI Semester

Executive Summary

This project titled STUDY OF EXISTING SYSTEM IN HEALTH INSURANCE

done by me for accomplishing the objective.

What: - My project deals about the study of existing system in health insurance.

Why:-In future I intend to get linked to any of the insurance companies looking at betterprospect of insurance in future.

When: - I conducted my project from 1st March to 1st April 2008.


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How: - This project is done by observing and analyzing the various insurance companies

in market and its shortcomings.

INDEX

1. ABOUT THE UNIVERSITY

2. ABOUT THE COLLEGE

3. INTRODUCTION TO THE HOSPITAL

4. INTRODUCTION TO THE TOPIC

5. AIM

6. OBJECTIVE

7. METHODOLOGY

8. INSURANCE:AN INSIGHT

9. ABOUT HEALTH INSURANCE


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In 1964, under the Act of Legislature Madhya Pradesh, the university was

established. Over the journey of forty years it has expanded and diversified itself in

various academic fields. At present it has 32 Technical Departments imparting P.G.

courses in multidisciplinary fields such as management education, social sciences,

engineering, computer, biotechnology & I.T. and other sciences. The university has

approximately 40000 students at its campus. With its resources of facilities,

infrastructure and other academic inputs to provide specialized and high quality

education for preparing future professionals.

ABOUT THE INSTITUTE (IMS)

IMS is driven by the mission:

Excellence in all areas of performance of everyone associated with the Institute and

to impart quality education.

Its underlying philosophy being :

Where changing is a tradition and tradition, a way of life;

Where learning is an identity and identity, a strength; and

Where creativity is character and character, a part of soul.

"In this ocean of knowledge, we pursue education."


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The objective of my project is to analyze the market of health

insurance in our country by going into the details of various insurance companies

and finally giving suggestions to make it more accessible to the people.

METHODOLOGY

1. Going the net to find out the details of various insurance companies to find

out their facts and figures. .

2. Visiting various insurance companies to know about them.

3. Designed a questionnaire to study the views of people.


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INTRODUCTION

The country is still struggling to come to grips with the liberalization and the

resultant opening up of the industry. The down of the first year in the new

millennium was hardly 26 days old and the whole nation was preparing for the

ceremonial republic parade when a devastating earthquake shattered the western

part of the country. It left behind a large trail of damage and colossal life o human

lifes and property. The event has struck a severe blow to the insurance industry

which is yet to recover from the tremors.

Globally USA has been undisputedly strongest country in the world, both in terms

of economic consideration as well as military might. The Americans has always

prided themselves over these facts which in facts have never been put to question or

doubt, at least in the recent years. All this myths of strength have been shaken by a

few terrorist attacks on the World Trade Centre and the Pentagon on September 11

and the whole country, the whole World gaped in utter disbelief and dismay. The

tragic event of Sep 11 2001, have affected individuals and business to an

unprecedented degree. Once again the one industry which had to beard the major

burnt was insurance albeit the effect this time was spread over a wider canvas-the


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It is a system by which the loses suffered by the few are spread over many,

expressed to similar risks

Insurance is based on two principles

Principle of large numbers.

Low of probability

HEALTH INSURANCE

Health insurance is a is a form of groupinsurance, where individuals pay premiums

or taxes in order to help protect themselves from high or unexpected healthcare

expenses. Health insurance works by estimating the overall "risk" of healthcare

expenses and developing a routine finance structure (such as a monthly premium, or

annual tax) that will ensure that money is available to pay for the healthcare

benefits specified in the insurance agreement. The healthcare benefit is

administered by a central organization, which is most often either a government

agency, or a private or not-for-profit entity operating a health plan.

History and evolution
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The concept of health insurance was proposed in 1694 by Hugh the Elder

Chamberlain from the Peter Chamberlain family. In the late 19th century,

"accident insurance" began to be available, which operated much like modern

disability insurance. This payment model continued until the start of the 20th

century in some jurisdictions (like California), where all laws regulating health

insurance actually referred to disability insurance. Patients were expected to pay all

other health care costs out of their own pockets, under what is known as the fee-for-

servicebusiness model. During the middle to late 20th century, traditional disability

insurance evolved into modern health insurance programs. Today, most

comprehensive private health insurance programs cover the cost of routine,

preventive, and emergency health care procedures, and also most prescription

drugs, but this was not always the case.

HOW IT WORKS: THE PROCESS

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 care costs that will be covered by the

health plan are specified in advance, in the member contract or

Evidence of Coverage booklet. The individual policy-holder's payment

obligations may take several forms

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

to purchase health coverage.

Deductible: The amount that the policy-holder must pay out-of-pocket

before the health plan pays its share. For example, a policy-holder might

have to pay a $500 deductible per year, before any of their health care is

covered by the health plan. It may take several doctor's visits or prescription
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refills before the policy-holder reaches the deductible and the health plan

starts to pay for care.

Co-payment: The amount that the policy-holder must pay out of pocket

before the health plan pays for a particular visit or service. For example, a

policy-holder might pay a $45 co-payment for a doctor's visit, or to obtain a

prescription. A co payment must be paid each time a particular service is

obtained.

Coinsurance: Instead of paying a fixed amount up front (a co payment), the

policy-holder must pay a percentage of the total cost. For example, the

member might have to pay 20% of the cost of a surgery, while the health

plan pays the other %80. Because there is no upper limit on coinsurance, the

policy-holder can end up owing very little, or a significant amount,

depending on the actual costs of the services they obtain.

Exclusions: Not all services are covered. The policy-holder is generally

expected to 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

dollar amount. The policy-holder may be expected to pay any charges in

excess of the health plan's maximum payment for a specific service. In

addition, some plans have annual or lifetime coverage maximums. In these


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cases, the health plan will stop payment when they reach the benefit

maximum and the policy-holder must pay 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-

pocket maximum, and the health plan pays all further covered costs. Out-of-

pocket maximums can be limited to a specific benefit category (such as

prescription drugs) or can apply to all coverage provided during a specific

benefit year.

Prescription drug plans are a form of insurance offered through many employer

benefit plans in the U.S., where the patient pays a co-payment and the prescription

drug insurance pays the rest.

Some health care providers will agree to bill the insurance company if patients are

willing to sign an agreement that they will be responsible for the amount that the

insurance company doesn't pay, as the insurance company pays according to

"reasonable" or "customary" charges, which may be less than the provider's usualfee.

Health insurance companies also often have a network of providers who agree to

accept the reasonable and customary fee and waive the remainder. It will generally

cost the patient less to use an in-network provider.

Health Insurance companies are now offering Health Incentive accounts (HIA), to

reward users for living healthy and making healthy choices, like stop smokingand/or losing weight, may get you funds added into your Health Incentive Account,

which may lower your out of pocket costs. The health incentive accounts also carry

over from year to year but once you leave the program you lose those benefits in the

HI Average provided during a specific benefit year


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PURPOSE

The purpose of health insurance is to help people cover their health care costs.

Health care costs include doctor visits, hospital stays, surgery, procedures, tests,

home care, and other treatments and services.

DESCRIPCTION

Health insurance is available to groups as well as individuals. Government plans,

such as Medicare, are offered to people who meet certain criteria.

Group and individual plans can be further classified as either fee-for-service or

managed care. Cancer patients may have specific concerns, such as the freedom to

select specialists that play a factor in choosing a health care plan. Fee-for-service

plans traditionally offer greater freedom when choosing a health care professional.

Managed care often limits a patient to health care professionals listed by the

managed care insurance company


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GROUP HEALTH PLANS

A group health plan offers health care coverage for employers, student

organizations, professional associations, religious organizations, and other groups.

Many employers offer group health plans to employees and their dependents as a

benefit of working with that particular employer (medical benefits). The employer

may pay for part or all of the insurance cost (premium).

INDIVISUAL HEALTH PLANS

These type of health care plans are sold directly to individuals


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HEALTH CARE REGULATIONS

The Health Insurance Portability and Accountability Act (HIPAA), passed by the

U.S. Congress in 1996, offer people rights and protections regarding their health

care plans. Because ofHIPAA, there are limits on preexisting condition exclusions,

people cannot be discriminated because of health factors, there are special

enrollment requirements for people who lose other group plans or have new

dependents, small employers are guaranteed group health plan availability, and all

group plans have guaranteed renewal if the employer wishes to renew. In summary

these rights and protections include:

Portability. This is the ability for a person to get new health insurance if

a change is desired or needed.

Availability. This refers to whether or not health insurance must be

offered to a person and his or her dependents.

Renew ability. This refers to whether or not a person is able to renew

his or her health plan.

Questions to Ask the Doctor
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What types of insurance do you accept?

Does your office file claims for patients?

Will your office get pre-authorization for procedures where it is

required?

Do you have a list of providers for my type of insurance in case a referral

is necessary?

If an experimental procedure is recommended, what costs will be

involved?

COMMON COMPLAINTS OF PRIVATE COMPANY

Some common complaints about private health insurance include:

1. Insurance companies usually only re-price their coverage annually. This

means if one becomes ill, and is covered by a health insurance policy, and

that illness will continue and be subject to a re-priced policy that person may

find that their insurance premiums have increased to an amount they might

not be able to afford. However, some states have rules and regulations which

can limit price increases on certain types of health insurance coverage.

2. If insurance companies try to charge different people different amounts

based on their own personal health, people may feel they are unfairly treated.

Exceptions to this differential in pricing can be found when an individual

(and their dependents) become insured under a pre-existing pool of insured

such as a group of employees insured through their employer. In that

instance, the underwriter assesses the financial risk based upon the entire

group (sometimes referred to as a 'risk pool'). In these situations, a person


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with little or no medical expenses in their recent history will pay the same

premium cost (and be subject to the same co-pays and deductibles) as

someone who has had a large amount of medical expenses in their recent

history.

3. When a claim is made, particularly for a sizable amount, insured may feel as

though the insurance company is using paperwork and bureaucracy to

attempt to avoid payment of the claim or, at a minimum, greatly delay it.

One large industry survey suggests that claim processing times improved

between 2002 and 2006. More claims are being submitted electronically;

however, 29 percent of claims were not received by the insurer until more

than a month after the date on which medical care was provided. The

percentage of claims being adjudicated on an automated basis is also

increasing. 14 percent of claims are "pended" by the insurer while additional

information is requested or the information on the claim is verified. On

average, pended claims are delayed by 9 days. Over 95 percent of the

remaining "clean" claims are processed within 30 days; 57 percent are

processed within one week.

4. Health insurance is often only widely available at a reasonable cost through

an employer-sponsored group plan and online for individuals.

5. In the United States, there are tax advantages to Employer-provided health

insurance, whereas individuals must pay tax on income used to fund their

own health insurance, although a small number of pre-tax health plans exist.

6. Experimental treatments are generally not covered. This practice is

especially criticized by those who have already tried, and not benefited from,

all "standard" medical treatments for their condition.

7. The Health Maintenance Organization (HMO) type of health insurance plan

has been criticized for excessive cost-cutting policies in its attempt to offer

lower premiums to consumers.

8. As the health care recipient is not directly involved in payment of health care

services and products, they are less likely to scrutinize or negotiate the costs
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of the health care received. The health care company has popular and

unpopular ways of controlling this market force.

9. Some health care providers end up with different sets of rates for the same

procedure. One for people with insurance and another for those without.

.

INSURANCE COMPANIES: An Overview

Policy Coverage

The policy covers medical expenses:

Incurred as an inpatient during hospitalization for more than 24 hours,

including room charges, doctor/ surgeon's fee, medicines, etc.

30 days prior to hospitalization.

60 days post hospitalization.


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Day Care expenses incurred on advanced technological surgeries and procedures

like Dialysis, Radiotherapy, and Chemotherapy requiring less than 24 hours of

hospitalization.

Key Benefits

One Policy One Premium for the entire family.

Income Tax benefits under Section 80D.

No health check up required up to the age of 45 years (as on last

birthday).

Hassle free claims procedure.

Additional Benefits

FREE Health coupon - Avail free health check coupon for any 1 member in

the plan.

Up to 2-year Cover - We offer a continuous 2-year protection with no

increase in premium in the second year. This one time payment of premium

for 2 years takes care of your renewal Hassles next year. Option for 1 year

cover also available

Claim Process

Health - Cashless Settlement


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Cashless claims facility is available only at our network hospitals. This list of

network hospitals is enclosed with your policy. Under this facility you just sign the

bills at the time of your discharge and we shall settle the amount directly with the

hospital.

Under cashless facility, claims can be of two types:

Planned

Where the insured or covered family member(s) is aware of the hospitalization 2-3

days in advance.

Fax / submit the pre-authorization form to TPA with doctors comments.

This form is available online and also at all our network hospitals .

The TPA faxes pre-authorization form with approval within 2-3 hours.

Avail the health treatment.

On your discharge, the TPA settles bills with the hospital.

Emergency:


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Where the insured or covered family member(s) meets with a sudden accident or

suffers from a bout of illness that requires immediate admission to the hospital.

Rush the patient to the hospital.

Patient avails the treatment.

Family submits the pre-authorization form to TPA with doctors comments.

This form is available online and with all network hospitals.

The TPA faxes pre-authorization form with approval within 2-3 hours.

On discharge, the TPA settles bills with the hospital.

Health - Reimbursement Settlement

Reimbursement claims facility is available at both the network and non-network

hospitals. The reimbursement claims process is as follows:

Patient avails the treatment.

Settle the hospital bills directly by paying the relevant charges.

Submit the relevant bills / documents for the claimed amount to the TPA.

The claims will be settled in 7 working days, from the time of submission of

bills.

Documents Required


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Duly completed claim form (available with all network hospitals).

Original bills, receipts and discharge certificate / card from the hospital.

Bills from chemists supported by proper prescription.

Investigation test reports and payment receipts, supported by the note from

attending medical practitioner / surgeon prescribing the test.

Doctors referral letter advising hospitalization in non-accidental cases.

Nature of operation performed and surgeons bill and receipt.

Any other documentation / information as required by the TPA

Policies

Tata AIG Life Insurance announced the launch of three life insurance policies

exclusively designed for children Assure EduCare 18, Assure Educare 21 and

Assure Career Builder in Mumbai. These juvenile life insurance policies from Tata

AIG work like an additional parent extending support to take care of the future of

the child.

Assure EduCare 18, Assure Educare 21 and Assure Career Builder have been

designed keeping in mind the funds needed to meet the university and specialization

education expenses of a child and also offer an insurance cover. While Assure

Educare 18 and Assure Educare 21 are endowment life insurance policies maturing

with the child attaining the age of 18 years and 21 years respectively, the Assure

Career Builder is a money-back life insurance policy maturing with the child

attaining the age of 27 years.


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Mr. Ian J Watts, Managing Director, Tata AIG Life Insurance, said, "We are

delighted to offer three life insurance products tailored exclusively to meet the

educational needs of children and also offer insurance cover. Considering the costs

involved for pursuing higher education and also the competitive environment that a

child is exposed to, the need for planning the education of a child is an important

aspect for any parent."

"We have designed our juvenile life insurance policies keeping in mind the most

important thing a parent wants for his child, helping them provide for a bright

future for the child and also offering them an insurance cover. These plans help the

insurer get an uninterrupted cash-inflow at regular intervals to take care of the

education expenses of ones child", Mr. Watts added.

Assure Educare 18 and Assure Educare 21 are participating endowment plans that

mature on a policy anniversary with the insured attaining the age of 18 years and 21

years respectively. These policies offer complete risk protection with guaranteed

benefits like Guaranteed Addition, that is 10 per cent of the sum assured of the

basic policy is payable if the insured dies after 10 years or with the maturity of the

policy; and guaranteed education amount, which is 20 per cent of the sum assured

of the basic policy on maturity of the policy.

The third juvenile life insurance offering Assure Career Builder is a participating

modified anticipated endowment (money back) plan that matures on the policy

anniversary following the insured attaining the age of 27 years. The cash payments

payable following the insured attaining the age 18, 21, 21 and 27, will not reduce the

death benefit payments if death occurs before maturity.

Additionally, these three juvenile policies also offer non-guaranteed benefits like the

reversionary bonus declared annually and credited to the policy and a terminal

bonus based on accrued reversionary bonus, payable upon death or upon maturity

of the policy if its in force for more than ten years. Further, the policyholder can

also take the 'Payor Benefit Rider' along with the basic policy. This rider ensures


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continuity of the policy by waiving-off all future premiums on the policy in the event

of death or disability of the premium payer.

These juvenile life insurance policies further add to the range of innovative life

insurance products introduced by Tata AIG in the last one year.

Tata AIG Life Insurance has simplified the claims processing system for

policyholders. The company's staff is visiting major hospitals and advising people

on how to expedite claims.

Tata AIG's customers can also call the 24-hour toll-free help line and get immediate

assistance and advice on the claims process. A special 24-hour help line has also

been set up.

Mr. Sunil Mehta, Country Head and Chief Executive, American International

Group (AIG), said Tata AIG had activated the Claims Catastrophe Management

Plan (CCMP) that was envisaged to meet claims under such calamities.


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ING Vysya Life - An Overview

ING Vysya Life Insurance Company Limited a part of the ING Group the worlds

largest financial services provider^ entered the private life insurance industry in

India in September 2001. Headquartered at Bangalore, ING Vysya Life is currently

present in 246 cities and has a network of over 300 branches, staffed by 7,000

employees and over 51,000 advisors, serving over 5.5 lakh customers

Product Portfolio

ING Vysya Life follows a customer centric approach while designing its products.

The Companys product portfolio offers products that cater to every financial

requirement, at all life stages.

In fact, the company has developed the Life Maker a simple tool which can be used

to choose a plan most suitable to a specific customer based on his needs,

requirements and current life stage. This tool helps you build a complete financial

plan for life at every life stage, whether the requirement is Protection, Savings,

Investment or Retirement. Suitable products from ING Vysya Life Insurances

product portfolio for each such requirement, makes selection of your plan an easy

exercise
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The Company aims to make customers look at life insurance afresh, not just as a tax

saving device but as a means to live life to the fullest. It believes in enhancing the

very quality of life, in addition to safeguarding an individual's security.

Distribution Channels

ING Vysya Life has a diversified distribution platform. While Tied Agency remains

the strongest channel, the Alternate Channels business within ING Vysya Life is one

of the fastest growing distribution channels. ING Vysya Life has strengthened its

position as the unparallel leader in the life insurance industry in cooperative banks

tie ups. The company currently has tie ups with 130 cooperative banks across the

country. The Alternate Channels division has Banc assurance, ING Vysya Bank,

Corporate Agents and SMINCE.


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QUESTIONNAIRE

1) Are you aware of HEALTH INSURANCE polices? If yes then how many

members of your family are insured?

2) Which types of health insurance policy do you hold- either long term or short

term?

3) Are you satisfied with polices and procedures relating your health insurance

policies? If not, then what recommendations you suggest to better your

policy?

4) At present which companys policy are you holding and would you to buy

policies of others companies or not? If yes, then which would you prefer?

5) Do you like the concept of broker between you and the company? If no, then

what should be the strategy according to you?

6) What do you think is the present status of health insurance in our country?

7) Are you satisfied with the present status? If no, then what do you suggest to

the policy-making companies to do to attract members?


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8) Do you think the claim process laid down under the policy of the company is

suitable or not? Whether it is a lengthy process? To shorten it what should

you suggest?

9) Do you like the inclusion of other schemes under your policy? If yes, then

what type of the scheme would you prefer, either cash increasing schemes or

some types of incentives given often a fixed interval?

10) Do you (senior citizens specially) receive policy renewal letters from

insurance companies regularly? If not then what would you like to suggest.

11) In this competition era, health insurance policy recently launched by LIC of

India, would be successful in its policy? If no, then what steps it would take

to make its scheme better then its rival?

12) How do you feel the insurance companies should do to educate the people of

our country regarding the better future effects of being insured?

13) Is there a need to revamp the insurance companies and if so which areas will

you could suggest some techniques which should be adopted by the

companies?


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CONCLUSION

In India there is limited experience of health insurance. Given that government has

liberalized the insurance industry, health insurance is going to develop rapidly in

future. The challenge is to see that it benefits the poor and the weak in terms of

better coverage and health services at lower costs without the negative aspects of

cost increase and over use of procedures and technology in provision of health care.

The experience from other places suggest that if health insurance is left to the

private market it will only cover those which have substantial ability to pay leaving

out the poor and making them more vulnerable. Hence India should proactively

make efforts to develop Social Health Insurance patterned after the German model

where there is universal coverage, equal access to all and cost controlling measures

such as prospective per capita payment to providers. Given that India does not have

large organized sector employment the only option for such social health insurance

is to develop it through co-operatives, associations and unions. The existing health

insurance programmes such as ESIS and Mediclaim also need substantial reforms

to make them more efficient and socially useful. Government should catalyze and

guide development of such social health insurance in India. Researchers and donors

should support such development.


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REFERENCES

Bibliography

Health care magazines

Health Care express

Health insurance magazines

New papers

Catalogs of Health Insurance Company

Web Pages

www.google.com

www.healthcareexpress.come www.healthinsurance.com

www.answers.com
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