Page 306 - DMGT303_BANKING_AND_INSURANCE

Unit 14: Marine and Motor Insurance

(iii) Critical Illness - Bajaj Allianz Notes
(iv) Health Shield - Royal Sundaram
6. Employer provided Insurance Systems
7. Member Organisation (NGO or Cooperative)-based Systems

Health Insurance Issues in India

1. Focused and increased public spending on primary and health care services

2. Reform of ESIS and CGHS
3. Restructuring of premiums
4. Increase in visibility and awareness (advertisements)
5. Discourage specific exclusions for disease(s) in health care policies

6. Encouragement of health insurance for those especially vulnerable

14.8 Payment Obligations

The individual policyholder's payment obligations may take several forms.
1. Premium: The amount policyholder pays to avail the health plan coverage each month/
year.
2. Deductible: The amount that the policyholder must pay out-of-pocket before the health
plan pays its share.
3. Copayment: The amount that the policyholder must pay out of pocket before the health
plan pays for a particular visit or service. For example, a policyholder might pay a Rs.500
copayment for a doctor's visit, or to obtain a prescription. It is paid each time a particular
service is obtained.
4. Coinsurance: The policyholder must pay a percentage of the total cost. For example, the
policyholder might have to pay 20% of the cost of a surgery, while the health plan pays the
rest 80%.

5. Exclusions: Not all services are covered. Some medical services may be excluded.
6. Coverage limits: Some health plans only pay for health care up to a certain amount. The
policyholder may be expected to pay any charges in excess of the health plan's maximum
limit for a specific service. Some plans even have annual or lifetime coverage maximums
whereby the health plan will stop payment when they reach the maximum, and the
policyholder must pay all remaining costs rest of life.
7. Out-of-pocket maximums: Here the policyholder's payment obligation ends when they
reach the out-of-pocket maximum, and the health plan pays all further covered costs.
8. Capitation: An amount paid by an insurer to a health care provider (a doctor/nursing
home/hospital), in return of which the provider agrees to treat all members of the insurer.

9. In-Network Provider: A health care provider (a doctor/nursing home/hospital) 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 deal within network provider.

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