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ACCESS Conference: Reducing Vulnerability of the Poor -Health Insurance

-500 million people have no access to specialist care as 80% of specialists live in urban areas. 40% of hospitalization expenditure of the poor is managed by borrowing money or by selling assets.

-Health insurance has penetrated only 3% of population due to high premiums, poor service delivery, and exclusion of diseases.

-Health insurance schemes in India include state schemes (for tertiary care-expensive illnesses) and RSBY (secondary care), which is heavily utilized.

-Use of technology (hand-held/mobile devices) are a good investment because they become a source of data and can be used to prevent fraud.

-Dr. Arjun (of SAS Poorna Aarogya Healthcare)  is a surgeon and shared a personal experience. While he was operating, he was called out to help a 3 year old girl who had come in for emergency care. The girl's parents earned Rs. 60/day and the consultation fee was Rs. 100 (or almost 2 days of labour). When she was diagnosed, the parents didn't have enough money to buy the appropriate medications and went to a quack who gave 2 injections for Rs.20. The girl got temporarily better, but the injections failed to kill the microorganism, and she later died of meningitis. Dr. Arjun decided to step away from medical practice and is instead working on developing financial products to help the poor access quality healthcare services.

-According to Dr. Arjun, the problem with traditional insurance programs is that  i) they are very focused on scale and ii) the products are inflexible; the same product will not work everywhere

-The SAS healthcare program works with NGOs and MFIs to issue health cards to their beneficiaries. Clients pay a membership fee and get quality treatment through a network of private hospitals.

-Treatment is cashless and includes hospital stay, surgeries, and outpatient diagnostics.

-The SAS program also places a facilitator ( an MFI staff member) within the hospital to assist the client with claims processing and processing of test results. Operational cost is high but this is another step against fraud and helps ease the process for clients.

-SAS Claims Settlement Process: i) Members visit network hospital    ii) MFI facilitator checks health card, coordinates check-up, creates  new claim   iii) Physician reviews claim in online system and and pre-approves claim within 15 min    iv) Member is treated and discharged; treatment is cashless     v) Hospital sends invoice to SAS at end of month    vi) SAS reviews claim details and settles claim amount

-RSBY and other schemes focused on mobile and ID technology; SAS invested in technology that converted ultrasounds/x-rays to images that can be uploaded in real-time. This was implemented in hospitals that had internet access

-This technology has been able to prevent fraud in regard to healthcare providers performing unnecessary operations.

-SAS program started with 5000 members in 2010 and currently has about 300,000 members, 126 network hospitals, 96,000 outpatients, and 4200 in-patients treated and health benefits of Rs. 17 million provided since inception.

-Mr. Paul Thomas of ESAF Microfinance provided the MFI perspective. MFIs have done life insurance but very few have done health insurance.

-2004-2005 study found that client default was not intentional; prevalent illnesses had resulted high hospital payments and loss of work

-Need for education to convey the concept of insurance; most do not think about it up until the moment they are hospitalized. ESAF has conducted awareness programs through narratives at cluster-level meetings.

-Challenges of MFI: If a claim is rejected, it damages the relationship with the client and it is difficult to communicate these concerns to clients. Currently, MFIs are not allowed to collect an admin. fee even though there is cost to enroll and service members. Insurance companies also need to develop flexible products, and MFIs should be given a buffer for amount of money administered.

-Fraud is an issue across all sectors. 2 major types of fraud: i) patient doesn't actually go to the hospital  ii) most of the fraud is due to fake or incorrect reports at the hospital level. For example, a patient goes in with stomach pain, the hospital is forced to place the case in a 'disease package' that is not accurate. Fraud by hospitals also consists of a hiking up of cost as soon as they see an insurance card.

-Cost of fraud ultimately gets added to the following year's premium. If you have inflation of healthcare costs, the clients following the protocol suffer and the insurance model fails.

-MFIs can play the role of distributors but may not be able to do fraud management. Insurers build fraud management in-house or work with 3rd parties.

-2 ways to control fraud: i) can be caught by analytics/data (i.e disproportionate claims in certain areas) or  ii) having a community-level gate-keeper or an MFI staff member who can monitor the process at the level of client-hospital interaction.


  1. Health Insurance will make a good social improvement in rural areas. Many of the one always part of it with a good support of Gov. The gov should need to change their policy to maintain the latest faults.
    For related writing work search thesis writing service


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