Transcript Document

Social Security is the need
of the hour for Developing
Countries
Social Security
• Social security systems ensure the
minimum level of living to the needy
by public assistance, and they also
promote public health and social
welfare.
Social Security systems
• They play three roles :
• 1) Deal with factors that cause needy
circumstances
2) Minimum level of living
3) Promote public health and social welfare.
Social Security in foreign countries
• United States :
Income Security. Funded by tax
revenues. The law, however, provides for
unemployment insurance, health services, human
services with people with disabilities, medical
services for the elderly and medical assistance in
addition to pension insurance.
Social security in foreign countries
• France : Sickness insurance and old age
insurance.
• United Kingdom : Income security such as
pension and child allowance.
Social Security in India
• India had an effective, economic and emotional
security in joint families, crafts communities and
guilds, customs & rites of individuals, and
panchayats. However, now the joint family system is
breaking to nuclear families thus requiring a new
framework for social security.
• India being a Social, Democratic Republic it
is the duty of the state to provide for social
security schemes. A Socialist State is one
that accepts the responsibility for providing
and ensuring Social security to all its citizens
without discrimination.
Social Security in India (contd..)
• Social Security in India would require
a) Minimum employment scheme
b) Health insurance
c) Maternity insurance
d) Pension
e) Children’s education
f) Life insurance
g) General insurance like cattle insurance.
• The working population in India can be
divided into
1. Organized sector comprising of Government
Sector, Public Sector and Private Organized
sector
2. Unorganized Sector
• The Organized Sector has benefits like Gratuity, PF and
pension. Hence does not require subsidy from the Government.
• The BPL in the Unorganized Sector would require Subsidy from
the government.
• Total Workforce (1999-2000) 393.21 million
- Organized Sector
38.93 million
- Balance under Unorganized Sector.
The total Outlay required for Providing Social Security to the
Unorganized Sector would be beyond the budgetary provisions
of the Government also.
•
Hence it is suggested that Social Security be
divided into 3 levels
1. A basic level where the State bears Primary
responsibility for providing minimum level of Social
Security
2. Beneficiary makes a contribution to the cost
3. Schemes that confer additional benefit beyond the
basic level
• A family which is living Below Poverty Line
gets most affected if the breadwinner
expires or if somebody in the family has to
be hospitalized for some major illness.
• LIC realizes its Social Responsibility. It
created a Social Security Fund in the year
1988-89 for subsidizing the premium for
insurance cover to weaker sections of the
Society. As on 31.3.2006 the size of the fund
was 808.25 crores.
• Janashree Bima Yojana was launched on 10.8.2000
to provide life insurance protection to the rural and
urban poor persons below poverty line and
marginally above poverty line at low cost.
• It has an add on benefit in the form of Shiksha
Sahayog Yojana where Scholarships are given to the
children of the members of Janashree Bima Yojana
Eligibility
• Member should normally be the head
of the family
• Persons below or marginally above
poverty line
•
between age 18 and 59
• Minimum group size 25
• 44 occupations have been identified
so far.
Revised Benefits From 15.08.2006
• Natural death: Rs.30,000
• Accident benefit
– On death: Rs. 75000 /- to the
nominee
– Total permanent disability:
Rs.75000/- to the beneficiary
– Partial permanent disability:
Rs.37500/- to the beneficiary.
Premium
• Rs. 200/- per annum out
of which
– Rs.100/- by member/
nodal agency
– Rs.100/- from social
security fund maintained by
LIC Of India
Nodal Agency
•
Shall Mean
1. Panchayats
2. NGO’s
3.Self Help Groups
4. Any Other Institutionalised
Arrangements To Collect Premium
•
It Will Act For And On Behalf Of The Insured
Members
•
To obtain application cum nomination form
•
Incorporate the details in register of members
and copy to be given to LIC of India
Work of nodal agency
• 50% of the premium +
proposal papers + list
of members.
• Verification of age.
Reimbursement of expenses to
NGO’s for introducing JBY
• FOR N.B.
– Minimum Members Should Be 250
– For The First 2500 Lives Rs. 4 Per Member
– Balance Rs. 2 Per Member
– Maximum Rs. 50,000/-
• FOR RENEWAL
– Group Size above 250
– Rs. 2/- Per Member
– Maximum of Rs.10,000
Claims
• Documents to be enclosed for claim
• Claim-cum-discharge form, attested copy
of the death certificate
• For accidental claims
1) Post Mortem Report
2) Copy of FIR
3) Police Inquest Report
•
LIC settles the claims by sending
account payee cheque favouring the
Banker Of The Beneficiary /Nominee
Shiksha Sahayog Yojana
Eligibility
• Students studying in 9th to 12th standards (Including
ITI Courses).
• Parents Covered Under Janashree Bima Yojana.
• If student fails and is detained in the same
standard, he will not be eligible for scholarship for
the next year in the same standard.
Benefits
• Scholarship of Rs. 300/- per quarter per child will
be paid for a maximum period of four years.
• For student to become eligible for scholarship the
parent should have been covered under JBY.
• Benefits restricted to two children per family.
Identification Of Beneficiaries
• Nodal Agency should identify the students.
• The Nodal Agency should guide the members to fill
up the application forms for this purpose.
• The list of beneficiary students along with the
details should then be forwarded to the concerned
P&GS unit.
Administration
• Scheme will be administered by LIC
• Scholarship will be disbursed to the beneficiary
through the Nodal Agency.
• Nodal Agency has to furnish LIC with the necessary
data of the eligible students.
• Nodal Agencies are required to maintain records and
submit certificates / details of utilization of
scholarships quarterly to LIC.
Our Achievement
• There are 4.62 crore families living below
poverty line in Inida.
• We have covered more than 1.5 crores lives
under social security schemes.
• However, it is a long road ahead yet to be
travelled.
LIC’s MICROINSURANCE
PRODUCT
JEEVAN
MADHUR
JEEVAN MADHUR
• SIMPLE SAVINGS RELATED LIFE INSURANCE PLAN
• PREMIUM MODE ----WEEKLY / FORTNIGHTLY /
MONTHLY /QUARTERLY / HALF- YEARLY / YEARLY
• SUM ASSURED BETWEEN Rs.5,000/- AND Rs.30,000/-
BENEFITS
• MATURITY BENEFIT : Payment of the Maturity Sum
Assured along with vested bonuses, if any.
• DEATH BENEFIT : Payment of an amount equal to
total premiums payable during the entire term of
the policy along with vested bonus, if any.
• ACCIDENTAL BENEFIT : Equal to Death Benefit Sum
Assured.
• AUTO COVER FACILITY AVAILABLE.
Health Care in India
Source :NIA Seminar & Insurance news
• The total value of the health sector US$ 34 Billion, 6% of GDP, one
of the highest in Asia
•
•
•
•
Of this 15% publicly financed,
4% social insurance,
1% private insurance
remaining 80% ---out of pocket as user-fees (75% of which goes to
the private sector)
• 2/3rd users ----out-of-pocket
• 90% ---- poorest sections
Health Insurance in India
•
•
•
•
•
11 non-life Insurance companies including 4 PSUs regulated by Govt. ( IRDA)
25 licensed TPA’s
Total premium recorded as on March 2005: Rs.1300 Cr. ( $ 260 million)
Indian Health Insurance Industry grew at the rate of 27% ( last fiscal).
Current population covered by some form of health insurance is 12% out of which
mediclaim is 1.4 %.
•
How does the Health Insurance Industry looks today
Traditional Insurance (Mediclaim)
1%
ESIS & CGHS
3%
Railways
1%
Social /Mandatory Insurance
4%
NGO/CBHI (Self funded)
3%
Source :NIA Seminar & Insurance news
Experience Hodgepodge
• Though the health-care insurance industry was worth Rs.5,000crore in
FY00-01, a growth of more than 200% over these years.
• the lapse ratio has not improved around 25-30% of mediclaim polices
lapse in a year.
• the total number of non-life insurance rejected claim complaints filed,
mediclaim accounts for about 65-70%
• In case of rejected claims, companies need interface with the
customer directly instead of the customer having to deal with third
party administrator
Source :NIA Seminar & Insurance news
Cont…
• The industry estimates no specific reasons for the non-renewals,
• Difficulties in making health insurance more accessible to customers
• the grievances due to large numbers of rejected claims
• lack of services cause customers to default on payments or
•
switch to other companies
• Claims in urban areas is 40% higher than semi urban areas
• As the government provides highly subsidized medical facilities, a majority
of the people are not very keen on investing in health care.
Pros & Cons of TPA’s
Purpose
• Electronic maintenance of the enrollment database
• Arrangement for the Network Hospital for extension of cash less
treatment.
• Issuance of the card
• Issuance of Authorization for all the admission occurring at the Network
Hospital.
• Claim Processing and Administration services till the settlement.
• Call Center services through National Toll Free No
• Generation of periodic MIS on Premiums, Claims and Utilization.
Source :NIA Seminar & Insurance news
Results
• Impersonal dealing with the patients
• Unnecessary interference felt by doctors on their working ways
• Incase of claim rejection TPA’s taken to as “the bad man”
• Nexus between TPA’s and local hospitals
• Rationalized medical fee structure remained a dream
• Standard medical practices remained a dream
As the cost needed by TPAs for rendering the promised services in the current
health infrastructure would be too high to be afforded under the health
plans in the market
The market & the people
•
Setting up of Health Insurance Regulatory Authority
•
Standalone Health Insurance companies should be promoted
•
Area-wise Standard medical and hospital charges
•
standard medical practices should be promoted
•
the combined effort of state governments and the companies under the
guidance of the regulator and the central government to be harmonized.
The Provider
•
Network of Quality care providers in tune with health insurance companies’
interest
•
Accommodate & promote alternative medicines and such practices so that
qualified doctors take to it
(Based on www.ahip.org, www.kaiserpermanente.com)
Road Ahead
Principle – Quality, Access and Affordability
* QUALITY -
* ACCESS –
for health care, and Insurance services.
for all Indians through public and private coverage
Source : AHIP Board of directors report
The market & the people
•
Setting up of Health Insurance Regulatory Authority
•
Standalone Health Insurance companies should be promoted
•
Area-wise Standard medical and hospital charges
•
standard medical practices should be promoted
•
the combined effort of state governments and the companies under the
guidance of the regulator and the central government to be harmonized.
The Provider
•
Network of Quality care providers in tune with health insurance companies’
interest
•
Accommodate & promote alternative medicines and such practices so that
qualified doctors take to it
(Based on www.ahip.org, www.kaiserpermanente.com)
Conti…..
The Insurer
Product Designing
•
Data to be classified and made heterogenic through Actuarially recommended
medical underwriting.
•
Proper database is to be maintained.
•
Wide range of products as per consumer needs should be provided.
•
Different health products for different categories of diseases & regions.
•
Providers should be involved in product designing.
•
Formulating proper outpatient strategies along with pharmacy policy
•
Delimiting exclusions and pre-existing medical conditions
(Based on www.ahip.org, www.kaiserpermanente.com)
Conti….
Marketing
•
•
•
Incentive to Hospitals and agents for promoting health products.
Creating awareness among people of target market
Insuring through various organized sectors such as municipalities, state governments,
private and public sector companies, gram panchayats, schools and colleges
Claims
•
•
•
Credit facility at point of service so as to reduce uncertainty concerning the time frame
within which reimbursement will take place.
Greater efficiency in the processing of claims through rationalized fee structure &
standard practices stipulated by the regulator and given way through different products.
Proper claim administration set up. IT –network for proper data administration and claim
settlement.
Vigilance
•
•
Accountability and transparency of the health company practices & providers
Continuous Morbidity Investigation Bureau (CMIB) to function within the company in
order to continuously monitor the changes required in the products.
(Based on www.ahip.org, www.kaiserpermanente.com)
Thank you