Health Insurance Scheme

1
Health Insurance Scheme

• Govt. of India budget speech 2004-05

2
References

• Directive from
• Secretary, Financial Sector, Govt. of India
• MDs of Public Sector General Insurance
• Through Chairperson GIPSA
• Importance of Health Insurance in Govt. of
  Indias priorities at National Advisory Council
• Note from Planning Board, Govt. of Kerala
• The scheme details in Malayalam and full policy
  particulars

3
Approximate Cost

• 16.66 lakhs BPL ration cards throughout state
  would convert into approx. 1666 BPL families per
  panchayat
• The average family size in sensus 2001- 5No.s
• Slab/family Rs.248/-
• Premium/Panchayat 248x1666Rs.413168/-
• Govt. of India Subsidy Rs. 49,98,00,000/- for
  entire state

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NACs health card

• A National health insurance plan, to be largely
  implemented through public hospitals. Health
  cess may be considered to cover expenses
• Plan for one hospital/1 lakh population over the
  next five years
• A health worker for every 1000 population
• A sanitation plan that ensures a toilet in every
  household
• Improving primary healthcare centres
• Setting up 10 task force groups on groups on
  specific issues of health reforms

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Health Insurance Subsidy
6
Problem

• In the past poor people were very poor to save
  and spend towards health insurance
• Trend has now changed and even poor can
  contribute to health insurance against illness
  and accidents
• State need to invest more on education, water
  supply, social security including pension and
  therefore states capacity to invest on health
  proportionate to demand will be limited.

In this situation, health insurance is a better
alternative for poor people to get better health
care at low cost
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From the letter of Mr. Indra Singh
SisodiaSecretary (Financial Sector), Govt. of
India

• A new Group Health Insurance Scheme through
  public sector non-life Insurance companies is
  being introduced.
• The insured will be members of Self-Help Groups
  (SHGs) and other credit linked groups (CLGs) who
  avail of loans from banks or cooperative
  institutions.
• Under the group health insurance scheme, the
  premium will be Rs. 120/- per person, but the
  insurance cover would be for a sum of Rs. 10,000.

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Part I
Viswa Arogya Padhathi

• Maximum Hospital Charges for family or a single
  person - Rs. 30000/-
• For one illness Max. limit Rs. 15,000/-
• For whole family Max. limit Rs. 30,000/-

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Viswa Arogya Padhathi
10
Part II
Viswa Arogya Padhathi

• Accident death of Head of family (within 6 months
  of accident) Rs. 25000/-

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Part III
Viswa Arogya Padhathi

• Admitted In case of accident or illness of
  earning member of family (Head of family) can get
  Rs. 50/- for 15 days (except first 3 days)

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Objective

• Around 31.43 of the total population are under
  BPL group.
• They includes tribal people, fisher folk,
  housemaids, and people with disability,
  urban-poor and a few others.
• These people need absolutely free medical care
  both in patient and outpatient care.
• Even though the treatment in govt. hospitals are
  free for BPL families, the non availability of
  required service facilities in Govt. Medical
  Institutions they have to seek the facilities in
  the Private Institutions for investigation and
  other service facilities.
• So a system to support the Medical Care of this
  group is evolved for the benefit for the BPL
  families

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Key Activities

• Each Panchayath has to identify household of BPL
• The family will be consisting of Husband, Wife
  and children and (Two dependent) parents.
• Each household BPL will have to be provided with
  Health Insurance Scheme
• To provide medical expenses incurred during
  hospitalisation and special investigation in all
  types of illness
• Only one policy will be issued to each family

14
Key Activities

• A credit card (smart card) system of policy can
  be evolved
• To be implemented on a pilot basis in three
  districts viz Thiruvananthapuram, Thrissur and
  Palakkad
• Health Insurance Scheme need a greater role for
  the Panchayath in administering the scheme and
  fixing the range of benefits and beneficiaries

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Time Need

• The Policy will be issued to each family and one
  policy shall cover a period of One year

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Rate of Premium

• The scheme is contributory in nature for which
  part of the premium will be meet by the family
  and part by the State Govt. and part by the LSG.
  
• The premium to be collected based on the
  population distribution as per the census 2001.
• Assuming that the population is maximum in the
  age group of 30 to 65 years, the premium works
  out Rs. 250/- per family per year for a benefit
  of Rs. 20,000/- per family.
• The benefit will be for the hospitalisation
  expenses of the member of the family put together.

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Benefits under the scheme/ Sum insured

• The cost of medicines, Diagnostic services and
  other supplies required for the treatment of the
  admitted patient can be purchased from outside
  based on the prescriptions of the Govt. Medical
  Officer.
• Max. limit Rs. 30000/- per family per year

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Procedure for Hospitalisation

• At the time of admission, the patients ration
  card will be produced before the counter at the
  hospital where it will be verified and the smart
  card issued. The card will contain the name of
  an SMO of the locality.
• The work will be done by a separate agency like
  Kudumbashree which will be responsible for the
  preparation of the smart cards and the
  maintenance of the database.
• A new form of case sheet will be issued in the
  hospitals for the BPL family members.

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Service Provider

• The implementation of the scheme required a
  Service Provider who conducts the verification
  facilities at the hospital counter and undertakes
  the preparation of smart cards with the Case Book
  for the eligible in patients.
• The charges for the service provider also has to
  be taken into account.
• Kudumbashree network may be the organisation
  suitable for the purpose.

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Prescription Pattern

• The doctors prescribe medicines for the
  inpatients and if the medicines are not available
  with the hospital the same can be purchased by
  the SMO. Prescription of high priced brands of
  the same drug has to be avoided. The doctors
  prescribing the medicines may abide by the
  prescription regulations fixed by the Govt.

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Private Hospital Participation

• Designated private hospitals may also be
  permitted to extend the service as a supplement
  to the Government effort for better IP facility.
  The Govt. will be notifying such hospitals and
  the rates chargeable for BPL members treated.
• In case of any charges are levied by the
  government on hospital facilities, they will also
  be paid for by the Insurance Company

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Outpatient Services

• It was pointed out that outpatient services
  should also be brought within the purview of the
  scheme.
• OP IP are by their very nature totally
  incomparable. They are treated separate in
  hospital management.

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Outpatient Services

• The Scheme was meant to address an area of
  limitation (viz. large scale out sourcing of
  diagnostics, drugs and supplies)