Workshop on

Health Insurance
Presented by,
SASTHA KUMAR.V
 ABOUT THE CEO
O Mr. Sastha kumar. V, a seasoned professional with 26
years of experience in academia and industry. With a
Double Major in Management, he is a specialist in his
domain areas and has been instrumental in setting up
companies and their administration.
O He also possesses a Licentiate and an Associateship at
the Insurance Institute of India, Mumbai. He is a
resource person for various IIT’s and IIM, Kozhikode.
O He has held various positions in National and
Multinational companies and currently is the CEO at
Maven WESTA Private Limited.
 Maven WESTA Private
Limited
O Maven WESTA Private Limited is a private company
incorporated on 07 January 2019 having its foray into
- Leading NRI property management.
- HR Consulting
- Career Guidance and Mentoring
- Business Consulting includes Project Preparation and
Funding options
- Placement Training
- Business and Individual Liasioning
- Industry – Institution tie-up
- Insurance Claim Process Outsourcing
- Event Management
OBJECTIVES OF WORKSHOP
O Basics of Insurance
OMarket Scenario Analysis
OInsurance Policy
OClaims Process
OClaims Redressal
 What is Insurance?
 Insurance is a means of
protection from financial
loss.
 Its a arrangement by
which a company or the
state undertakes to
provide a guarantee of
compensation for
specified loss, Damage,
illness, or death in return
for payment of a
specified premium.
 Includes health,
accidents, property, life
etc.
 HISTORY OF INSURANCE

O Lloyd'sinsurance market began in 1688 at

Lloyd's Coffee House in London, owned
by Edward Lloyd. It became famous
among sailors and merchants for reliable
shipping news and marine insurance.
Eventually, it evolved into a place where
people could bet on the safe return of
ships.
 In India
O Insurance in India began in the year 1870; The first
policy issued was in 1870 by The European & The
Albert‘.
O The first Indian insurance company was 'Bombay
Mutual Assurance Society Ltd.' formed in 1870.
O As the 'Swadeshi movement was catching up many
more Indian companies were formed.
O The insurance companies were nationalized in 1956.
O There were 170 insurance companies and 75 provident
fund securities which got merged and on 1 of Sept 1956
Life Insurance Corporation of India was born through
enactment of law in parliament called LIC Act 1956.
PRINCIPLES OF INSURANCE
O Principle of Utmost Good Faith/ Uberrima
Fides.
O Principle of Insurable Interest.
O Principle of Indemnity.
Government regulation of
Insurance
 The Insurance Regulatory and
Development Authority of
 The Insurance Act, India (IRDAI) is
an autonomous, and statutory
1938 is a law body under
originally passed in the jurisdiction of Ministry of
Finance , Government of India.
1938 by British

India to regulate Tasked
with regulating and licensing the
the insurance sector. It insurance and reinsurance industries
in India. It was constituted by the
provides the broad Insurance Regulatory and
legal framework Development Authority Act,
1999,an Act of Parliament passed by
within which the the Government of India and came
into force and super ceded LIC Act
industry operates 1956. The agency's headquarters are
in Hyderabad, Telangana.
 What is Health
insurance?
O Health Insurance is defined as "coverage that provides
for the payments of benefits as a result of sickness or
injury.
O Can include insurance for losses from accident,
medical expense, disability (temporary/ partial/ total)
or accidental death.
O "A health insurance policy like other policies is a
contract between an insurer and an individual/ group
in which the insurer agrees to provide specified health
insurance cover at a particular "premium" subject to
terms and conditions specified in the policy.
Why health insurance considered
to be non life insurance
O Health insurance is considered separate from life
insurance because health insurance covers medical
expenses and treatments during one's lifetime,
aiming to reduce financial burden from healthcare
costs.
O In contrast, life insurance provides financial
support to beneficiaries upon the insured's death,
focusing on replacing income or covering expenses.
O Their distinct purposes and coverage make them
categorized differently in the insurance industry.
 NEED FOR HEALTH
INSURANCE
O Mitigation of financial loss arising from
hospitalization.
O Health insurance policy normally cover the pre
and post-hospitalization expenses. These
expenses can include diagnostic tests,
investigations, medications, doctor fees etc.
Post-hospitalization expenses are incurred when
a person needs to go through follow-up
treatments after hospitalization for a definite
period of time.
 Market scenario of
insurance in India
O The Indian insurance industry has become a
significant sector with life insurance
contributing about 3% of GDP and non-life
insurance at 1%​.
O Over the next five years (2024‒28), it is forecast
that total insurance premiums will grow by
7.1% in real terms.
O The pandemic accelerated digital adoption, with
a significant portion of customers now preferring
online modes for insurance services​.
Future Outlook
O India's insurance sector is projected to grow at an
average rate of 7.1% annually between 2024 and 2028,
the highest among G20 countries​(Stock Market News)​.
O Innovations such as Insurtech are expected to play a
crucial role in this growth, with India being a significant
market for insurance technology investments​ (India
Brand Equity Foundation)​​(Stock Market News)​.
Challenges
O Despite the growth, insurance penetration remains
relatively low, and there is a large protection gap,
especially against natural catastrophes, with 93% of
exposures uninsured​(Stock Market News)​.
 What is Underwriting ?
 Underwriting is the process of examining, accepting
and or rejecting insurance risks, classifying those
selected, in order to charge the appropriate premium
for each.

 The purpose of underwriting is to spread the risk

among a pool of insured in a manner that is equitable
for the insured and profitable for the insurer.
 Who is an
Underwriter?
O An underwriter in the insurance industry evaluates and
assesses risk, determines policy terms and pricing, and
decides whether to accept or reject the risk so solicited.
They play a critical role in risk management.
Broad Classification of
underwriters
Technical
Field cum primary
Underwriters
Underwriter
O Agents & the Agency O The person actually

development concluding the contract of

insurance there by
managers.
committing the contractual
O They come in personal liability and obligations.
contact with the client O He is required to be
and have an excellent vigilant while scrutinizing
opportunity to assess each and every document
the risk. submitted and ensure that
O It is essential that the the basic underwriting
requirements are abided
they should help to by.
screen out bad risk
 Process in claims
O TPA
O Company Management Claims

Pre requisite of claims

 24 hours of hospitalization
 Diagnosis should be followed by a prognosis
Exemptions
 Listed day care procedures
 WHAT IS TPA?
O TPA stands for Third Party Administrator
and is defined as an organization or individual
that handles the claims, processing, and
reporting components of a self-funded health
benefits plan.
O • TPA helps simplifying insurance process.
 Role of TPA in health care management

O 1. Manage Policyholders Records

O 2. Issue the Health Cards to the Insured
O 3. Smooth Claim Processing and Settlement
O 4. Provide Value-Added Services
O 5. Strengthen the Hospital Networks
O 6. Maintain Customer Service Center -
Helpline Facility.
 Empanelment of hospitals

O An empanelled hospital is a healthcare facility

that has been listed by a TPA or an insurance
company or government organization to
provide cashless medical treatments to its
policyholders or beneficiaries. The
empanelment process ensures that the hospital
meets certain quality standards at pre
determined or agreed cost.
 What is Cashless
claims ?
O A cashless claim in health insurance is a
type of claim you file under your policy
when you are hospitalised for need of
medical attention.
O In a cashless claim, your Insurance
company/ TPA along with the hospital will
coordinate and settle the bill based on
your policy coverage.
 What is Reimbursement
claims?
O A reimbursement claim is a formal request
made by a policyholder to their health
insurance provider, asking for a refund or
compensation for out-of-pocket medical
expenses incurred.
CLAIM REJECTION SCENARIO
What is Grievance redressal?

O A customer grievance is a formal or informal

complaint or concern expressed by a customer
regarding a product, service, or past experience
offered by the business. It is a way for customers to
communicate their discontent with a specific service
or product to interact with the company..
 Who is an Ombudsman?
O Ombudsman is an independent and non-partisan
officer of the legislative who supervises the
administration. He deals with specific complaints
from the public against.
O He has the power to investigate, criticize and report
back to the legislature, but not to reserve
administrative action.
O Administrative injustice mal administration, (or
may proceed on his own information in similar
circumstances)
 CO PA Act 1986
O The Consumer Protection Bill, 1986 seeks to
provide for better protection of the interests of
consumers and for the purpose, to make provision
for the establishment of Consumer councils and
other authorities for the settlement of consumer
disputes and for matter connected therewith.
 CONCLUSION

 Understanding the fundamental principles of

insurance,
 Assessing the current state of the insurance market,
understanding the role of adjusters and claims
assessment,
 Knowing the process for resolving disputes related to
insurance claims.