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  • Universal Health Insurance Scheme by Govt. of India

    Not to be confused with Oxfam’s Universal health coverage (UHC), Universal Health Insurance Scheme (UHIS) is vastly different from the Oxfam product. First of all the Universal Health Insurance Scheme is offered to Indians by the Indian Government. Both APL (Above poverty Line) and BPL (Below Poverty Line) families can apply for this scheme.

    Why Was Universal Health Insurance Scheme Launched?

    There are 4 public sector general insurance providers who have implemented Universal Health Insurance Scheme with the intention to enhance people’s access of health care especially for families at or below the poverty line. This not only includes individuals but groups or families. For starters this scheme comes with a medical expense reimbursement of up to Rs.30,000 for hospitalization which is floated amongst the entire family, along with death cover caused by accident for Rs.25,000 which would be given to the main earning member of the family and also a compensation for the loss of the earning member with Rs.50/given to the family for a up to 15 days. The Universal Health Insurance Scheme (UHIS) is revamped to serve the purpose of meeting the needs of families falling under the poverty line. The premium used to be Rs.100 and has now been changed to Rs. 200 for an individual, Rs.300 with family members of five and finally Rs.400 for a family of 7, with no compromise on the benefits.

    Main Features of the Universal Health Insurance Scheme:

    The features of this policy are mainly based on the fact whether the individual or family fall under the Below Poverty Line or over it:

    APL (Above Poverty Line) Features:

    1. The UNIVERSAL HEALTH INSURANCE POLICY for groups is available for families or groups that consist of more than 100 families. Each of the families insured is covered of all eligible members i.e. insured persons under a single group policy only. This means that different categories of eligible members are not be allowed for coverage under different group policies. Hence, it is not allowed for any unnamed group policy to be issued..
    2. This scheme is issued in the name of the Group/Association/Institution with a simple list of names of the members which includes his/her eligible family members who are insured forming the policy.
    3. The scheme provides coverage in the form of medical treatment reimbursements for Hospitalisation expenses for illness/diseases that have been contracted or any sort of injury that has been sustained by the insured individual. Under the circumstance that any claim becoming admissible under policy, the insurer through TPA (Third Party Administrator) will pay to the Hospital/ Nursing Home or Insured individual the amount of such expenses which is again subject to limits as would fall under different heads and are reasonably and incurred through necessity in respect to the place in India by or on behalf of such Insured Person but not exceeding Sum Insured (all claims in aggregate) for that person as stated in the Schedule in any one period of insurance.

    BPL (Below Poverty Line) Features:

    1. The UNIVERSAL HEALTH INSURANCE policy will be available to both Individuals as well as in Group just as it is available for APL families.
    2. Each member who is insured is covered under one group policy only, just as it is in the case of APL families.
    3. The Individual Policy will be issued in the name of the earning head of family with details of insured family members. The Group policy will be issued in the name of the Group/Association/Institution (called insured) with a schedule of names of the members including his/her eligible family members (called Insured persons) forming part of the policy.

    Universal Health Insurance Policy Coverage/ Benefits:

    The coverage provided by this scheme is mainly based on the fact whether the individual or family fall under the Below Poverty Line or over it:

    APL (Above Poverty Line) Coverage/Benefits:

    It is essential to note that the expenses incurred in total for any single illness is restricted to Rs. 15,000 maximum. Also, the insurance company's liability when it comes to Company's liability in claims admitted during the period of Insurance shall not be more than the Sum Insured of Rs.30000/- per person or family as mentioned in the Schedule:

    1. The scheme covers up to 0.5% of Sum Insured per day for Room, Boarding expenses as provided by the Hospital or Nursing Home.
    2. If the individual is admitted in the Intensive Care Unit (ICU) up to 1% of the sum insured per day can be claimed.
    3. Costs incurred for Surgeon, Anaesthetist, Medical Practitioner, Consultants, Specialists Fees, Nursing Expenses will be reimbursed for up to Rs.15% of Sum Insured per illness or Injury.
    4. Other costs that include Anaesthesia, Blood, Oxygen, OT charges, Surgical appliances, Medicines, drugs, Diagnostic material & X-Ray, Dialysis, Chemotherapy, Radiotherapy, cost of pacemaker, artificial limbs will be covered with up to 15% of Sum Insured per illness/Injury.

    BPL (Below Poverty Line) Coverage/Benefits:

    For families who fall under the BPL category, the families would get either health care or hospitalization benefits along with death through accident benefit of the head earner, through this policy. You also have added maternity benefits:

    Hospitalization Coverage/ Benefits: The scheme covers the reimbursement of Hospitalisation expenses for illness or diseases suffered or injury sustained by the Insured Person. It is essential to note that the expenses incurred in total for any single illness is restricted to Rs. 15,000 maximum. Also, the insurance company's liability when it comes to Company's liability in claims admitted during the period of Insurance shall not be more than the Sum Insured of Rs.30000/- per person or family as mentioned in the Schedule:

    1. The scheme covers Upto to 0.5% of Sum Insured per day for Room, Boarding expenses as provided by the Hospital or Nursing Home.
    2. If the individual is admitted in the Intensive Care Unit (ICU) up to 1% of the sum insured per day can be claimed.
    3. Costs incurred for Surgeon, Anaesthetist, Medical Practitioner, Consultants, Specialists Fees, Nursing Expenses will be reimbursed for Upto Rs.15% of Sum Insured per illness or Injury.
    4. Other costs that include Anesthesia, Blood, Oxygen, OT charges, Surgical appliances, Medicines, drugs, Diagnostic material & X-Ray, Dialysis, Chemotherapy, Radiotherapy, cost of pacemaker, artificial limbs will be covered with up to 15% of Sum Insured per illness/Injury.

    Maternity Benefits: Rs.2,500/- for normal delivery and Rs.5,000/- for caesarean delivery for a the delivery of a single child is covered under maternity benefits for BPL families through this scheme. A waiting period of a complete full year from inception of the policy is applicable. The above amount would also cover the medical expenses incurred in respect of newborn child upto 3 months. However, this benefit is within the overall limit of Sum Insured of Rs.30,000/-

    Personal Accident Cover to Earning Head: If the Insured individual who also has to be the earning head of the family should sustain any bodily injury resulting solely and directly from Accident caused by outward, violent and visible means, and if such injury shall within 6 calendar months (unless otherwise specified) of its occurrence lead to death then the insurance Company shall pay to the Insured the sum of Rs.25,000/- if solely due to accident. If the insured individual who has to be the earning head of the family shall sustain any bodily injury resulting solely and directly from Accident caused by outward, violent and visible means, and if such injury shall within 6 months generally of its occurrence lead to death then the Company shall pay to the Insured the sum of Rs.25,000/- if solely due to accident. Disability Compensation for Earning Head and / or Spouse of the Family: For this, the maximum liability of the Company is limited to Rs.750/- in all during the policy period If the Earning head of the family / spouse is hospitalized due to accident / disease /illness for which there is a valid claim admitted under Section I of the policy then after a waiting period of 3 days, the Company shall pay to the earning head of the family or spouse a compensation of Rs.50/- per day from the fourth day of hospitalization upto a maximum of 15 days per policy period.

    Eligibility for Universal Health Insurance Scheme:

    The eligibility requirements of this scheme is mainly based on the fact whether the individual or family fall under the Below Poverty Line or over it:

    APL (Above Poverty Line) Eligibility:

    APL: The family’s income is expected to be over the amount, making them eligible to be an APL family. Age Eligibility: This insurance scheme is available to people between the ages of 5 to 65 years. Children who are aged between the age of 3 months and 5 years can be covered as long as both parents are covered at the time.

    BPL (Below Poverty Line) Eligibility:

    BPL: The family’s income is expected to be less than the amount, making them eligible to be a BPL family. A certificate as proof thereof issued by an official not below the rank of B.D.O. / Tehsildar of Revenue Department of the concerned State Government has to be attached. Age Eligibility: This insurance scheme is available to people between the ages of 5 to 70 years. Children who are aged between the age of 3 months and 5 years can be covered as long as both parents are covered at the time.

    Premium Payment for Universal Health insurance Scheme:

    For APL Families:

    1. Premium for an Individual is calculated at Rs.365/- per annum
    2. For Families with not more than five members consisting of Insured, Spouse and first 3 dependent children the premium to be paid is Rs.548/- per annum.
    3. For Families with more than 5 family members and not exceeding 7 members including Insured, Spouse, first 3 dependent children and dependant parents Rs.730/- per annum.

      There is no Refund of premium for deletion of Insured Person in the event of Insured Person having made/recovered a claim under the Policy.

      Policy renewal is allowed through mutual consent. The insurance Company shall is not liable to give notice that it is due for renewal and the Company may at any time cancel this policy by sending the Insured 30 (thirty) days notice by Registered Letter at Insured's last known address and in such event the Company shall refund to the Insured a premium at a prorate basis for unexpired period of Insurance The Company shall however, remain liable for any claim which arise prior to the date of cancellation

    Period of risk Rate of premium to be charged
    Up to 1 month 1/4 of the annual rate
    Up to 3 months 1/2 of the annual rate
    Up to 6 months 3/4 of the annual rate
    Exceeding 6 months Full annual rate

    For BPL Families:

    Coverage Premium Insured's share GOI Subsidy
    Individual Rs.300/- Rs.100/- Rs.200/-
    Family with upto 5 Members Rs.450/- Rs.150/- Rs.300/-
    Family with upto 7 Members Rs.600/- Rs.200/- Rs.400/-

    Termination of the Universal Health Insurance Scheme:

    The Insured individual or group may at any time cancel this policy. When this happens the Company will refund the premium at Company's Short period rate only provided no claim has occurred up to the date of cancellation.

    FAQs on Universal Health Insurance Scheme:

    1. What do you mean by TPA, which seems to be an alternative for insurance providing company?

      TPA means a Third Party Administrator who, for the moment, has been licensed by the Insurance Regulatory and Development Authority, and is engaged, for a fee or remuneration, by whatever name called as may be specified in the agreement with the company, for the provision of health services.

    2. What are the benefits that are covered, under maternity, which is available only for BPL families?

      Maternity Benefit means expenses incurred in Hospital/Nursing Home arising from or traceable to Pregnancy, childbirth including normal Caesarean Section. This also includes medical expenses incurred in respect of newborn child upto 3 months.

    3. What are the conditions for claims other than the mentioned as benefit?
      • All claims under this policy shall be payable in Indian currency.
      • All medical treatments for the purpose of this policy will have done in India only.
      • Payment of claim shall be made by the TPA on behalf of the Company either to the Hospital or Nursing Home or the Insured Person as the case may be.
    4. What is the Claim Minimisation Clause?

      According to the claim minimisation clause the Insured family or person will have to at all times cooperate with a TPA / Company to contain claims ratio by making sure that the treatment charges and other expenses are reasonable and necessary and will be subject to further sub-limits as may be required. Hence, people need to be honest about their bills and not take it for granted.

    5. What is the Premium Adjustment Clause when it comes to Universal Health Insurance Scheme in India?

      If the Claim ratio is more than 80% of the premium paid, then the renewal rate will be adjusted to ensure that the claims ratio remains within 80% of the premium paid. To come to the claims ratio, the first 10 months will be taken into consideration. An average for the whole year will be taken and premium charged provisionally thereon. The final adjustment if any, has to be made at the end of 60 days in the new policy period post the full incurred claims figures are available. In the following years the claim ratio will be taken on the average of 2 or 3 years as the case may be.

    6. What is Protection of Policy Holders' Interest?

      In compliance to IRDA (Protection of Policy Holders' Interest) Regulations, 2002, the Company has opened grievance cell at Regional Office as well as Head Office. The policyholder may submit his complaint / grievance to the said grievance cell of the Company for remedial action.

    Conclusion:

    Despite the fact that Rashtriya Swasthya Bima Yojana (RSBY), which has been newly introduced, is fast picking up pace as a sufficing health insurance for BPL, and without premium requirements, Universal Health Insurance Scheme is supposed to targeted at BPL families, but APL families can enjoy its benefits especially for maternity, which is not covered in most regular health insurance policies.

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