CHAPTER II

REVIEW OF LITERATURE AND RESEARCH METHODOLOGY

2.1 REVIEW OF LITERATURE

In recent years, exploring the research output particularly in the areas of humanities
(management studies) and social sciences (economics, sociology etc.) have been treated
with an increasing concern among the researchers. Management is said to be in practice
ever since the dawn of civilization. Therefore the researcher has referred various sources
to understand the topic as well to update with past data, data sources and results, which
are useful for this study. Quite large numbers of people have expressed their opinion by
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way of publishing research articles, papers, doctoral thesis, reports published by regulator
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etc. The research work published by different experts is summarized as below.

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2.1.1 The paper on "Equity of health sector financing and delivery in India" by Cham C. Garg,
(1998) The major objective of this paper was to study the financing of health care system
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from the viewpoint of equity 1. Equity in health care examined with respect to i) equity in
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health care finance and ii) equity in the delivery of health care. The paper based on
secondary data sources. The paper revealed that, the viewpoint of public expenditure it
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has been found that even though both direct and indirect taxes are progressive in nature
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but in terms of government allocation of resources, rural areas have been neglected as
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most of the government expenditures have flowed to non-rural areas. Further the
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government expenditure between the preventive and curative services again tends to
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favor the urban and the richer groups. The allocation of government expenditure and
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provision between the center and the state tend to biased in favor of better off states,
which affects the poor in the poorer states adversely. Health care delivery has also been
biased against the unorganized sector and particularly the urban poor. It has been found
that even though the government has been making concerted efforts to improve the health
infrastructure in rural areas, the extent, level and quality of services are still very poor.
Even though more people live in rural areas, more hospitals and health personnel serve
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the urban areas. Finally it is concluded that the health care system as a whole is not
effective especially in terms of nation's resources devoted to health care vis-a-vis its
impact on the health status or provision of health care services and facilities equitably.

2.1.2 Ms. Indrani Gupta (2000) is a health economist wrote on "Private Health Insurance and
the Willingness to Avoid Health Costs"2. Her areas of research are health insurance,
health financing and demand for health care. She has considerable work on health
insurance. She tried to find out the solution for some questions like. Are Indians ready
for private insurance? Will there be demand for such insurance from all the sections of
the society? What will individuals look for when they "purchase" insurance to cover
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future risks, a product that is almost non-existent now in India? This paper attempted to
answer, based on data collected in Delhi from about 500 households through purposive
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sampling method. It is concluded with some findings and observations that, the
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willingness to participate in insurance programmes is the least among those who have
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some form of current coverage. These are mainly the middle class population in Delhi.
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On the other hand, those most willing to participate are the poorer households. At the
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same time, these households are unable to participate in programmes, or would be unable
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to participate because of the perceived high premium of the schemes. The well-off
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households from the high-income areas on the other hand are somewhere in-between
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these two extremes: they are more willing to participate than the middle class, but less
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than the poor class.

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The paper based on a deliberation of a one day workshop on health insurance involving
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2.1.3
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practicing doctors, representatives from insurance compames and health policy

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researchers. Dileep Mavalankar and Ramesh Bhat (2000) of Indian Institute of

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Management, Ahemedabad, presented the review of health insurance situation in India3 .

They concluded that, India has limited experience of health insurance. Given that
government has liberalized the insurance industry, health insurance is going to develop
rapidly in future. The challenge is to see that it benefits the poor and the weak in terms of
better coverage and health services at lower costs without the negative aspects of cost
increase and over use of procedures and technology in provision of health care. The
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experience from other places suggest that if health insurance is left to the private market
it will only cover those which have substantial ability to pay leaving out the poor and
making them more vulnerable. Hence, India should proactively make efforts to develop
Social Health Insurance patterned after the German model where there is universal
coverage, equal access to all and cost controlling measures such as prospective per capita
payment to providers. Given that India does not have large organized sector employment
the only option for such social health insurance is to develop it through co-operatives,
associations and unions. The existing health insurance programmes such as ESIS and
Mediclaim also need substantial reforms to make them more efficient and socially useful.
Government should catalyze and guide development of such social health insurance in
India. Researchers and donors should support such development.
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2.1.4 Mr. Shashidharan K. Kutty (2000) has tried to fill up the gaps through his doctoral
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thesis 4 . The main objectives were to develop a model of life insurance demand within a
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broader financial environment, in which the amount of life insurance purchased depends,
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not on the amount of protection an individual/household needs, but is instead determined

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with reference to a wider process of portfolio selection of financial assets. Mr. Kutty
adopted the methodology of conduct of survey, literature approach to life insurance. He
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sum up along with some learning' s that, the treatment of life insurance products from a
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customer and market standpoint rather than a supply driven perspective. Secondly, the
study of life insurance in a wider financial environment, with its role and value additions
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being examined in conjunction with other financial instruments. Similarly the issue of
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expectations is closely linked to factors that influence the purpose of purchasing a life
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insurance contract-like age and life cycle, income, socio-cultural and market conditions.
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Researcher has also outlined the portfolio model to show how the demand for the life
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insurance may be developed within a context of choice of assets. He has also considered
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the environmental imperatives that prompted the emergence of their trends. He has also
explored into the various implications of such value propositioning for supply side
processes in life insurance.

2.1.5 Mr. Ashok Laxman Wadikar, (2001) has recognized the need of innovativeness in the
insurance sector way back in 2001 and has presented a model in his doctoral thesis 5. He
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has mentioned that General Insurance of Company (GIC) is planning to introduce

'Managed Health Care' in India on the lines of international standards. The Union
Government has already granted in principle approval for it. Group insurance scheme
will be launched and will target corporate and institutions who would take to offer health
care benefits to their employees and it will be customized in keeping with the flexible
needs of the corporate clients. He has also pointed out that, training structure has created
in GIC but is not so effective. This research has offered a model focusing on six points
such as leadership, innovation strategy & investment, people strategy & investment,
organizational structure, organizational practice and the innovation climate. A very
comprehensive and crucial strategy is studied by Mr. Wadikar.
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2.1.6 K B S Kumar (2002) has rigorously stated in his article that, the growth in the health
insurance sector has been negligible in India despite the aspiring and optimistic vision of
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the Bhore Committee in 1946. Presently, the cost of medical care is escalating and the
service standards are deteriorating6 . In India, despite having a health care industry of over
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Rs.35 crore per annum, has not been able to attract the multinational insurance majors for
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venturing into health care business due to the strict norms. In addition, the present
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conditions are not friendly for insurers as well as the insured. The present Health
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Insurance market at a glance indicates loopholes in the indemnity products exist in the
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form of pricing. Pricing of products is most non-scientific, has an arbitrary loading

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pattern, even more arbitrary discount pattern, adjustment of premia is non-existent and
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bonus/malus clause is outdated. Mediclaim too carries along with it certain inherent
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problems like; it is the most primitive kind of product, has no restrictions, no adjustments
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and is almost pure charity to influential people. While at present, 1. 7 $ tn is spent on

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healthcare worldwide. In India by 2015 it is expected that this expenditure will be

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Rs.1.17 bn. The Insurance concepts are changing in healthcare with the insurers moving
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away from indemnity-based products to active involvement in managing the risk, as per
the consumer's demand. India, despite having a health care industry of over 35 crore per
annum, hasn't been able to attract the multinational insurance majors to venture into
health insurance business. While almost all the corporate giants in India got into
insurance sector, only a handful of the tie-ups could be made with multinational
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companies for health insurance. In conclusion, author has stated vanous reasons
responsible for the above-mentioned problem including functioning of IRDA and TP A

2.1.7 One more article by KBS Kumar (2002) stated that, India being a country with a huge
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population of one billion, projects a sorry state when it comes to health care . In its 55
years of free existence, it has been able to cover barely 3% of the total population with
any health insurance coverage. The crucial recommendations of committees like Bhore
Committee etc. are left in a state of abeyance. It is high time the authorities took
necessary action and provide this essential right to every Indian. The paper concludes
that, the authority has to conduct periodic reviews of the financial reports of the insurance
companies. The first blunder committed by the authorities concerned was neglecting
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Bhore committee's recommendations, which had a cascading effect on the sector. The
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governments have been enthusiastic and vigorous in setting up committees but failed to
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contain the same when it came to implementation. The poor health care in the nation had
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a direct impact on the health insurance sector. The lethargy of the authorities reaches its
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saturation. Liberalization of the insurance calls for a strict and stringent action by the
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Government and the authorities concerned. The Insurance Regulatory Development

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Authority needs to keep a vigil over the industry requisites like quality standards,
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financial regulations, policy holder's interest etc. Above all the Government must give a
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thought for implementation of Bhore committee's recommendations in order to adopt the

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universal health care concept.

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2.1.8 GRK Murty (2002) has presented article in journal on innovative idea for reaching to
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masses and use of available source for widening of health insurance through banks8 . He
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emphasizes that, the Indian healthcare delivery system is badly affect with many
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problems, notable among them being demographics, technological innovations in medical

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practices and regulatory measures. The age group of 60 to 80 is fast growing in India,
which means increased demand for healthcare and its costs. Besides, a great majority of
population is still confined to the unorganized sector with little or no access to healthcare
services. Innovations in medical sciences have no doubt increased the speed of recovery
from dreaded diseases but it also impacted the cost of medical treatment. The net result is
the exponential increase in the cost of healthcare. It is also becoming evident that the
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government, which is plagued with huge fiscal deficit year after year, is not in a position
to commit additional funds to improve the healthcare delivery. The existing insurance
services are not that easily accessible to half of the population owing to high up-front
premium cost. A need has therefore arisen to innovate low-priced ways of financing
healthcare. One such contemplated model is for banks to float a joint venture HMO not
only to sell health insurance and offer medicare at an affordable price, but also augment
their revenues via "operating-leverage."

2.1.9 In doctoral thesis (2003) on "Health Insurance" by Dr. S. P. Deshpande 9 has shown a
comprehensive and holistic analysis of Health Insurance sector. Healthcare management
is a key area of concern for policymakers worldwide and assumes special importance in
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the context of developing countries. The rise in healthcare costs usually rise at two to
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five times the general inflation and therefore providing quality healthcare at affordable
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prices is all the more challenging. The study based on secondary as well as primary data.
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Secondary data is used for comparative analysis of the healthcare sector, health financing,
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health insurance systems and health insurance products in the developed world vis a vis
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India. Primary data about claims and risk exposure is collected with regard to current and
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potential health insurance products. This data is used basically for estimating the cost of
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pure risk and the ultimate pricing of health insurance products after incorporating
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loadings. Thus the study is founded on a robust database. The collected data includes
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enough details so as to afford a good insight into the relevant issues. With the aid of
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comparative analysis, the researcher identifies the points of departure of the Indian health
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insurance industry from its Western counterpart. This may be indicative of the gaps in
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the Indian health insurance sector. However, as the researcher rightly emphasizes,
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merely borrowing certain products from the West, and grafting those in India may not
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work. Products suitable to the Indian market will need to be evolved thorough a
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discovery driven process. In particular, the absence of any government funded national
healthcare programme, preponderance several systems of medicine and lack of adequate
regulation argue for a different approach to healthcare planning with obvious
implications for insurance. He has undertaken a detailed analysis of the various kinds of
health insurance products in vogue. He notes that in India, it is the medical expenses
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insurance that is most popular. Disability income insurance is still at a nascent stage. He
also notes the predominance of group products in the health insurance market. Next, he
has addressed the issue of risk cost estimation, and pricing of health insurance products.
He recommends use of deductibles/stop loss limits which can have significant impact on
the cost of cover. He also recommends frequent surveys to assess Usual, Customary and
Reasonable (UCR) charges of a particular treatment. Such surveys can go a long way in
keeping costs under control and can also minimize morale hazard issues. He focused the
limitations inherent in using morbidity statistics for pricing if health insurance products in
India and suggests a more pragmatic approach. He discusses the Pure Risk Cost
methodology and the experience rating cost methods, as well as associated issues in
selection and underwriting, impact of deductibles on pricing, and major factors which
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have a bearing on premium computation. Based on the primary data collected by him,
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the researcher then undertakes the calculation of pure risk cost in respect of various
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' packages' of health insurance products. The basic parameters involved are probability
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of incidence of claim, and the average claims cost with suitable loading for medical
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inflation. He arrives at the final pricing figure after considering cost of procurement,
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expenses of management, reserves for catastrophes and profit margin. The methodology
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adopted is such so as to be sensitive to factors such as age, disease condition and

geographical location. To sum up, the study places health insurance in the wider context
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of healthcare management, offers comprehensive information on health insurance

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products available worldwide and their comparative analysis, and looks at the theoretical
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issues involved in pricing of health insurance products, and works out viable price ranges
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for various categories of such products based on the collected data on risk exposure and
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cost of claims in India. All in all, the study affords a keen insight into the dynamics of
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health insurance sector, and sketches out future directions.

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2.1.10 Mr. Sankara V. Mony (2004) has deeply given insight in his article that, why health
insurance is not growing? 10 In his straight forward vision towards health insurance has
pointed out several issues and aspects involved as an obstacle of health insurance. He
referred about awareness of health insurance; in India the concept of insurance as such is
low. Educated people more in urban areas know of some aspects of insurance,
particularly if the requirement is made compulsory by law, as in the case of motor third
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party liability insurance. Adverse selection is also a cause for health insurance. Young
age, affordable premium, principles and benefits of insurance and feedback system has to
introduce and developed in order to satisfy to all stakeholders. In the case of health
insurance it is the absence of data that is a major factor discouraging insurers from taking
up this line of business. Statistics in respect acceptability of an insurance product
depends to a great extent on the reasonableness of its price. To be able to charge an
appropriate price an insurance company would rely on statistics on past several years loss
or claims incidence. Life insurance is a classic example. The introduction of Third Party
Administrators (TPA) is a very encouraging move. However, it has run into problems
and it is expected that the issues will soon be resolved and the TPAs will play their
assigned role adequately. They should have technical expertise, manpower and dedicated
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systems to process health insurance claims. The institution of TPAs has to be

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strengthened and a well-run TPA sector will greatly assist in the expansion of the health
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insurance market. It is concluded that, insurers have to work hand-in-hand with the other
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stakeholders in the health sector. The size of the market and its potential are indeed very
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large. Insurers can play a very significant role in the improvement of the quality of life of
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the average Indian even as they expand the health insurance market for their benefit and
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those of the users. Efforts must continue to achieve significant growth of health
msurance
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2.1.11 Mr. Yogesh Lohia, (2004) firmly believes that, insurance should become an important
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issue 11 . But surprisingly India does not have comprehensive health insurance programme
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with the result that only small group of people belonging to the organized sector enjoy
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some measure of financial protection against illness. Mr Lohia has pointed out that
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health care has always been a problem area for India, a nation with a large population, big
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portion of which is below poverty line. Health sector in India is mainly limited to the
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primary health care systems managed by the government and other public health care
system in a traditional model of health funding and provisioning. Health insurance is a
financial mechanism that exists to provide protection to individuals and householders
from expenses incurred because of unexpected illness or injury. The case for health
insurance rests on three grounds such as illness can not be predicted, financial burden of
 35 ..

hospitalization is high and cannot be planned and the proportion of people requiring
hospitalization due to illness an any large population is small thus enabling risk pooling.
Customer demand should not be neglected. Customers these days are well informed and
aware and desire better quality institutes. The opportunities for well qualified
professionals are increasing. The government and people are using various health
financing options to meet health care costs. Improved economic situation, market forces
and the payment methods have also influenced the development and application of
medical innovation. To meet the demands of the customers it is necessary that the
insurance companies should introduce new products and provide customers with good
service. With rising healthcare cost, insurance companies are under pressure to offer
insurance protection that covers consumers without being prohibitively expensive.
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Pressures have always been on the rise in this segment to provide quality service that can
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meet the expectation of consumers, service providers and regulators. It is concluded that,
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once the initial groundwork is done there will be no stopping health insurance from
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becoming one of the most robust sectors of the Indian Economy. The message is clear.
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Insurers have a real and substantial role to play in the healthcare equation. But they must
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take a higher profile to engage the life science industry, healthcare providers and
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government to ensure that at the end of the day the insurance industry is not left holding
the burden for healthcare funding as consumers seek the best treatment at any cost,
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digging into the deep pockets of their insurers.

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2.1.12 Mr. Nimish R. Parekh, (2004) has presented his views through practical approach in
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article that, the success of health insurance is based on one of the key parameters in the
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computation of health insurance premium is the current medical cost 12 . In addition to

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this, a good understanding of the rate of inflation of medical cost is imperative in the
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accurate pricing of health insurance premium. Around the world, medical cost inflation
rates run at between 2 and 3 times economic (or wage) inflation. In India, medical cost
inflation over the last seven years has risen at a rate of between 18% - 22% per annum.
The Insurance Regulatory & Development Authority (IRDA) has taken a huge leap in the
health insurance market development by introducing regulations for TPAs. The IRDA
now needs to look ahead by facilitating the development of other important facets such as
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uniformity of data and information. Finally, it will be important for the IRDA to consider
the inclusion of Life Insurance companies in the Health Insurance arena-not just riders
but full-fledged health insurance as in many markets health insurance is considered to be
allied with the Life Insurance. Health insurance products will have to be evaluated on
their own merits and the critical medical loss ratio parameter will have to be brought into
the evaluation protocol. The primary responsibility of the state of health insurance lies
with the insurance company and not the TP A. In conclusion, the author suggested that,
if we are able to take these next steps prudently, I am sure that "Healthcare for all by
2020" will become reality rather than an empty promise towards a healthy India.
Insurance companies need to take a hard look at two major aspects of their health
insurance aspirations such as product design/ pricing and service provision capabilities of
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their administration partners. Mediclaim is the single biggest deterrent to the innovation
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and development of health insurance products due to its pricing. Insurance companies
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will also have to view their TP As as partners and not vendors. TPAs will be the deciding
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factor in the success or failure of each insures' health insurance aspirations.

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2.1.13 The Case Study of the Yeshswini Health Insurance Scheme for rural farmers and
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peasants in Kamataka presented by Professor, Sarosh Kuruvill (2005) along with his
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team members with the aims to document and analyze the case and to examine reasons,
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issues involved in project 13 . The team learnt after an examination of the first year of
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operations of the Yeshasvini health insurance scheme in Karnataka that there are a
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number of issues to consider in terms of criteria by which one can judge its success.
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From the perspective of providing coverage for life saving operations for people who
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would no have been able to afford the operations, the scheme is clearly an unqualified
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success. It covers a significant percentage of the target population, and has the potential
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to cover more. The rate of coverage is also very high (Rs. 200,000 per person per year)
and the highest compared to any similar schemes for this type of target population
anywhere in the world. A clear indicator of success is the number of people benefited in
terms of operations. However, a drawback of the scheme is that it does not cover the
poor farmer for all health related issues, but only for outpatient care and all expenses
connected with surgery. The things that are not covered (diagnostic tests, and medicines)
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continue to be a heavy burden on poor rural families, many of which will continue to
cause indebtedness. Given however those surgeries are generally required in life
threatening situations, the scheme provides a degree of health security for this population
that was impossible before. Whether the scheme can cover in future what is not covered
now remains an open question. To answer this question, the team would need better
information regarding the health status of the target population, or at least enough data to
develop an accurate actuarial assumption. It concluded that, stepping back, the key story
in this model is the law of large numbers being effectively used to provide a high degree
of health security to the poorest populations of the world. This is not a new story, to be
sure. The key innovative aspect is the success in mobilizing these large numbers, who are
geographically dispersed. The key lesson here is that existing organizations that connect
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people must be drafted as a means through which health security can be introduced. The
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transferability of schemes like this depends almost entirely on such organizations existing
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among the target population, and the existence of health care infrastructure of a
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reasonable kind. The second key lesson is that there needs to be a methodology by which
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the subscriptions can be collected from poor people from dispersed rural and informal
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sectors i.e., we need a system to collect their contributions (which research shows they
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are more than willing to pay) and to enroll people in the system. The team expressed that
health security should be provided to large sections of the population in developing
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countries which depends less on the resources, but more on mobilizing capacity and
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organization.
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2.1.14 Mr.Rajeev Ahuja and Ms.Alka Narang (2005) provided an overview of the emerging
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trends in health insurance for low-income groups in India in their article 14 . Based on the
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early evidence of universal health insurance and United Nations Development

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Programme (UNDP) sponsored health insurance pilots, some lessons on the design of
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insurance are drawn. The authors have focused on demand and supply factors of health
insurance. On the demand side, this is partly the result of the mushrooming of micro
credit organizations keen on introducing health insurance for their clients who take loans,
partly the greater experience from past initiatives of grass root non-government
organizations (NGOs) that introduced health insurance due to the felt needs of the
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community, as well as that of charitable trust hospitals who wanted to minimize default
payments. On the supply side, this development is complemented by the regulatory
requirement of Insurance Regulatory and Development Authority (IRDA) that makes it
mandatory for all insurance companies to extend their activities to rural and well-
identified social sectors in the country. There is an urgent need for public action in
building health security into the lives of the poor. Government and insurance companies
are expected to play significant role in introducing health insurance for low-income
people. Authors felt that for successfully running health insurance for the poor,
coordination among multiple agencies is needed. In order to extend insurance to low-
income groups three conditions are absolutely essential. One, the provision of a certain
minimum health care services of reasonable quality; two, the possibility of resource
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mobilization from the targeted segment so that part of the cost is recovered; and third, the
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presence of an implementing agency. One can surely reach to the low income group if
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these three factors fulfilled.

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2.1.15 Mr. K. Praveen Kumar (2005) has mentioned in his article that, health insurance 1s
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grossly underdeveloped in India as 3% of India' s population is covered under some form

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of voluntary health insurance 15 . He also agrees that, in a large diverse and complex
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country like ours, no single health insurance model can be successfully implemented.
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We have to also address community-based small HMOs, but without the burdensome
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minimum capital requirement currently in force by the regulators. There may also be
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need for regulation for the self-funded health plans by major employers who may not find
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insurance as a cost effective alternative. In India, presently the health insurance exists in
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the form of Mediclaim policy offered to the individual or any group association or
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corporate bodies. Although, total expenditure on health in India is nearly 6% of the

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entire GDP, the government spending is less than 25% against the average spending of
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30-40% in other developing countries. It is concluded that, to give health insurance and
related financing mechanism a chance, appropriate legislation and a constitutional
mandate, which brings healthcare into the social security ambit from a right framework,
will be necessary. For this to happen political will has to be generated and for the latter
civil society has to be activated to demand healthcare as a right. Only such pressure will
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create the conditions for bringing in universal insurance for healthcare with equity.
Healthy people are wealth of nations that is why it is being treated as indicator of a
nation's development.

2.1.16 Sampa Bhasin (2006) has focused several reasons through article 16. One of the major
reasons cited for major health insurers not entering the country has been the low
penetration, as also, the low spend on insurance as a component of the total health spend.
However, the same issues were not a deterrent for the life and non-life foreign majors to
enter this sector. Therefore, if the anomaly of the high capital requirement for health
insurance, which today is the same as life and general, is addressed, the interest of health
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insurance providers would be significantly higher in entering this segment and providing
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a higher degree of servicing to the consumers. In addition, the high commission's

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structure of the traditional distribution channels being used by the existing insurance
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players for distributing health products makes it more unattractive and raises the
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operating expenses, leading to negligible and negative returns on health insurance

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products. These issues will be addressed once the policy makers approve IRDA' s
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recommendation for a separate health insurance provider with lower capital requirements.
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The main issues that are being faced by the public are quality of service: especially, when
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facilities are owned by the plan giver, reimbursement delays: in cases, where the insured
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has settled the expenses and/or rejection of claims, limitations of services: either
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monetary restrictions on the amount available per year or exclusions of certain pre-
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existing and chronic ailments, inadequate information: regarding health, ailment,

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procedures, techniques, treatments and costs, provider malpractices, high cost: for
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comprehensive total care and advanced age and low penetration levels.
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2.1.17 Dr. George E. Thomas (2006) has studied in his doctoral thesis about managing change in
the general insurance regulatory mechanism of India from the perspective of
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organizational management and economic environment . The thesis has investigated
how Tariff Advisory Committee (TAC), a general insurance regulatory organization has
changed itself in line with the changing economic environment of the country. The
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objective of the study was to work out a programme for smooth implementation of
change in organization. This study is based on comprehensive case study. He has
discussed with senior executives and employees of TAC and executives of other
organizations. Findings from 120 of such discussions were tabulated. Attitudes of the
employees towards changes in TAC were studied from a sample of 20 employees and
measured on a 6 level perception matrix. Researcher has also referred secondary data
comprises of book, websites etc. The study offered few observations that, through TAC
has the core strengths to perform the functions proposed for it, is inferred that whatever
TAC can do well in its present identity can be done better if it identifies itself fully with
IRDA. While planning and implementing change TAC's change managers should not
lose sight of the following like, the organizations should have strategies to contain
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adverse factor like negative publicity, hostile industrial relations or even contingences
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like the board/government failing to appreciate the endeavors midway and withdrawing
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support. He also suggested that, TAC should be careful in dealing with the aftermath and
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consequences of change with the external world, it should develop an image of

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professionalism and credibility. Within the organization, it should create an atmosphere

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of trust congenial for frank feedback. The organization should demonstrate the
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willingness to listen, understand, accommodate and alter plans when required.

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2.1.18 An article based on a survey in seven locations by Mr. David M Dror, (2006) finds that
most Indians are willing to pay 1.35 per cent of income or more for health insurance and
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most people prefer a holistic benefit package at basic coverage over high coverage of
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only rare events 18 . The needs of the poor, and their demand for health insurance, depend
N
IV

on local conditions. Seven myths have been laid to rest in this article. We can state
E R

without doubt that there is a solvent market for health insurance among India's poor.
SI

However, tapping this huge market is contingent on product development that starts from
TY

a deep understanding of the clients' needs and wants. The insurance products must be
adapted to the heterogeneity of the consumer- base. Community-based endeavors can be
a powerful resource for process innovation and for gaining acceptance by the target
population, because nobody is closer-to-client, and no other body is as effective as
communities in implementing the local ethos that makes the local economy run. The
communities are also best placed to mediate an optimal balance between needs, costs,
 41

resources and supply, all of which are context-specific. Minor adaptations of products
developed for richer clients (and often in Europe or the US) are unlikely to find many
willing takers in the slums and villages, where reality is completely different. Becoming
familiar with the needs and priorities of the poor requires considerable innovation in
processes; the logistics for data mining, access to clients, selling and servicing of the
health insurance must be adapted to the context-specific social dynamics and local
infrastructure. However, the long tail of the cost distribution, implying that outlier costs
can be devastatingly high, makes it necessary to link local communities with a financial
mechanism of reinsurance and risk equalization, thereby enabling micro health insurance
schemes to benefit from economies of scale.

2.1.19 Paper by Mr.Ramesh Bhat and Mr.Nishant Jain (2007) based on survey, focused on the
SA

factors which affects on the renewal of health insurance policies 19 . These are generally
VI
TR

one-year policies and to remain part of the insurance poll, policyholders are required to
renew their policies each year. Understanding the factors that affect the demand and
IB
AI

renewal decisions to continue in health insurance programme is imperative for future

PH

growth and development of the insurance sector. Since health insurance is not
mandatory, it faces challenge of ensuring all policyholders renew their policies, as these
U
LE

policies are not sold for long-term. In health insurance generally short-term plan of one-
PU

year duration are sold. However, the studies on renewal of health insurance policies are
scanty. Generally, it is assumed that factors affecting the purchase will affect the renewal
N
E

decision. However, it is hypothesized that factors affecting renewal could be different

U

from factors affecting purchase decision. Survey was done in the Anand district of
N
IV

Gujarat. Charotar Arogya Mandal is offering a health insurance scheme called "Krupa" to
E R

people living in Anand and nearby districts. Members of this scheme get treatment at
SI

Shri Krishna Hospital, Karamsad that is a renowned hospital of that area. The main target
TY

segment for this is lower and middle-income population of this area. They find the
factors affecting health insurance renewal are not the same as factors affecting health
insurance purchase decision. This has important implications for the insurance companies
because they need to market the product and choose target customers in a manner to
ensure long-term continuity of policyholder in the pool. The results also suggest customer
satisfaction is significant factor in influencing the renewal decision of policyholder. This
 42

should prompt insurance companies to provide a good experience to the customer during
the period of the policy.

2.1.20 Mr. Alex George (2007) has critically reviewed rules, laws related to micro health
insurance, with special reference to the rural and social sector obligations of insurers and
20
the regulations governing the sector, including those of third-party administrators . The
underlying perspective is to serve those who are dependent on the informal economy for
their livelihood and for whom expenses on health are a major burden. He concluded that
fixing the obligation to rural areas to a percentage of the policies sold instead of the
premium income and ensuring that at least a certain part of these policies are sold to the
categories mentioned under social sector obligations can ensure some amount of equity in
SA

access to health insurance in rural areas. Regarding social sector obligations, instead of
the small number of policies, which is presently specified, IRDA should insist on a
VI
TR

certain percentage of policies to be sold to various categories of social sectors to make

IB

this obligation more responsive to Indian conditions, with 93% of the workforce in the
AI

informal sector and their dependent families having no coverage. It is true that the civil
PH

society organizations, which conduct their own micro health insurance schemes, need
U

more accountability and transparency in their functioning. Constituting a separate

LE

authority to regulate micro-insurance schemes with the participation in its management of

PU

informal sector trade unions, cooperatives, women's organizations, SHGs, NGOs, etc,
N

who are better informed and sensitive to the needs of the micro-insurance sector, will
E

enhance the development of this sector and also ensure transparency and accountability.
U
N

Channelizing the union government's subsidy under the universal health insurance,
IV

through the schemes registered and monitored by the proposed authority is likely to
E R

increase the reach of this initiative targeted for the BPL population. The author has urged
SI

that proposed authority should reduce the capital adequacy for registering micro health
TY

insurance organizations to a level proportionate to the membership, benefit package,

claims ratios, cost per member and administrative costs of such schemes. Some large
schemes could then register themselves as micro-insurance organizations, and the
medium and small schemes could federate among themselves. Capital adequacy required
under the IRDA Act for life and general insurance companies now is a whopping Rs 100
crore! The option to join as an agent of the insurance companies should be left to the
 43

management and members of micro health insurance schemes. In the event of their
choosing to join on a principal agent basis, there should be plans offered by the
companies, which do not exclude women in the reproductive age group, children and the
aged, and offer inpatient and outpatient care, diagnostics and surgical care. If the micro-
insurance schemes which are presently operating without any tie-up with insurance
companies are allowed to continue most of them will not require the services of TPAs as
their size of business is not economical for their intervention.

2.1.21 The editorial speech of "Maharashtra Herald", (2007) tried to create more awareness
about insurance benefits21. It says that, for medical security, we need to be more aware
about insurance benefits. As a negligible proportion of Indian population is covered
SA

under health insurance is something that needs urgent analysis. What is this aversion due
VI

to? Is it because a majority of people are unaware of the advantages of providing for a
TR

secure financial cover that may be required in case of ailment? Or is it due to the fact
IB

that most Indians, especially the huge middle class segment, are unable to afford the high
AI

premium rates of medical insurance? One of the reasons for this apathy towards health
PH

insurance could also be attributed to the failure of the insurance packages in reaching out
U

to the rural mass. Actually, insurance should be a form of protection against the high cost
LE

of medical treatment. Today, the healthcare industry is one of those that spins maximum
PU

profits and the best facilities and packages are available only for those who can afford
N

them. This means that the middle class and those below it are automatically debarred
E

from any access. A cardiac arrest, for instance, can easily work up a bill of not less than
U
N

Rs.1 lakh - an amount that many would find beyond their reach. As such, health
IV

insurance is an entity that provides for a pocket that can be dipped into during times of
E R

crisis. However, one factor that has people shying away from health insurance is the lack
SI
TY

of trust. Indian have now come to believe that companies in the business of collecting
money cannot be relied upon to part with it when the time comes for paying up. Then, a
pile of documentation is required and so is evidence of all sorts to be able to claim your
own money back. Things like these have to change. The article also emphasized that
insurance companies have to become more customer friendly rather than come across as
 44

wolves in the garb of sheep. New models need to be created to drive people to think of
msurance.

2.1.22 An article written by Mr.Mukesh Shivdasani, (2007) explains why healthcare costs have
shot up in the past few years and looks at ways in which better health cover could be
made available to people22. He suggests that insurance companies should work with
health service providers to give the best possible options to their customers. Healthcare
cost for individuals has raised 25-50% in the last five years. There are various reasons
for this such as, awareness has increased and diseases are being investigated in their early
stages and the use of high-end diagnostic technology and new modalities of treatment
with specialized care has pushed up costs. At present, premiums are mostly based on the
SA

customer' s health condition and demographic aspects like his age and the size of his
VI

family. But the Indian environment is going to change. Premiums will change according
TR

to the model we follow. In the US, premiums depend largely on whether one goes
IB

through an HMO (Health Maintenance Organization), which empanels hospitals and also
AI

guides the customer to an appropriate hospital, or through a Gold Standard one is the
PH

most expensive. In India, health insurance penetration is less than 5 % A lot of

U

expenditure on healthcare is financed by corporate and individuals. Insurance covers and

LE

premiums that are the same across all service providers may not be good for customers.
PU

They themselves want different levels of service. Demand is certainly going to crop up
N

for new kinds of insurance cover. Insurance will depend on the quality of healthcare
E
U

delivered and cost charged by the institutions. Hospitals should be graded on the basis of
N

quality and cost of care provided and fixes the premium accordingly. Insurers should
IV
ER

take into account the fact that there are demands for different levels of health service.
SI

2.1.23 Researcher himself attended and participated in a programme on "Health Insurance"

TY

(2007) wherein various experts have contributed their experience towards health
insurance management23. Mr. R.K. Murali Iyer, Research Associate, National Insurance
Academy, Pune, Dr. Ranjan, Management Consultant, Mr. George E. Thomas, Chief
Manager, TAC, Dr. Ketaki Washikar, Asst. General Manager-operation, MDindia
Healthcare Services (P) Ltd. , Pune, Dr.P.V.Bokil, Consultant, United Health Care,
Mumbai, Dr. Prakash Kondekar, Consultant Naturopath, Yoga & Bowen Therapist,
 45

Borivli (W) Mumbai and Dr. Mahesh Baldwa, Medicolegal Advisor & Doctor have
interacted and discussed during the programme mainly on the following issues:

health insurance scenario in India.

exclusions in Health Insurance products & Risk Management
health life styles v/s Health Insurance
loss prevention in health insurance
comparison of health insurance products

few issues of concern or barriers towards implementing a social health insurance

scheme in India.
With reference to these issues the speakers have addressed that, India is a low-income
SA

country with 26% population living below the poverty line, and 35% illiterate population
VI

with skewed health risks. Insurance is limited to only a small proportion of people in the
TR

organized sector covering less than 10% of the total population. Currently, there is no
IB

mechanism or infrastructure for collecting mandatory premium among the large informal
AI

sector. Even in terms of the existing schemes, there is insufficient and inadequate
PH

information about the various schemes. Data gaps also prevail much of the focus of the
U
LE

existing schemes is on hospital expenses.

PU

2.1.24 The report (2008) of USAID ( US Agency for International Development) pointed out
N

that, when health insurance is picking up in India, only 17 out of 1,000 people
E

hospitalized are getting reimbursement24 . Although hospitalization is the basis for all
U
N

health insurance, only 1. 7% of admissions are reimbursed and the average reimbursement
IV

is only Rs.258/- The report also points out that despite higher cost, majority of both rural
ER

and urban Indians prefer private care and the primary reason for this preference is the
SI

perceived inferior equality of public care. The report emphasized that~ both the private
TY

and public sector should provide insurance to more people in India. There is also great
need for social health insurance in India to bridge the financial barrier of rural and urban
healthcare.

2.1.25 Dr. George E. Thomas (2009) has given practical thought on the survival of TP As in
respect to health insurance in his article25. Sensitivity, responsibility and performance
 46

appraisal, these aspects should be focused seriously. In respect to appraisal, the right
questions to the right people or organization should be asked. The author has summed up
that, if the TPA system is to function as per its design it would create a market
environment of better care, lower claims and claims handing costs, lower premiums,
better insurance penetration and higher profits. The issues to be considered while
evaluating and assessing the functioning of TPAs is to find out how insurers can use TPA
system to achieve image, reducing insurers' workload and costs, making hospital system
more transparent and increasing customer trust in the insurance system. The author has
pointed out that, the TPA can be re-looked as the TPAs are after all only less than nine
years old in the Indian market. Perhaps, it is time to review the market environment and
TPAs growth and decide how it can be improved. After an objective analysis of the TPA
SA

system, insurers would be in a vantage position to take a knowledgeable decision. If they

VI

find the TPA system very good, they can decide to enjoy it; if it needs improvement, they
TR

need to mend it; if they find the system so bad that it can not be improved, they should
IB

end it; and if the situation is bad and they are unable to do anything about it, they have to
AI

endure it.
PH
U

2.1.26 Mr. K.S. Gopalkrishnan (2010) expressed during seminar that, the need for better co-
LE

ordination among the constituents of health insurance industry to make the health
PU

insurance portfolio profitable is required26 . He stated that, collection of data would be

N

very vital for the growth of the insurance industry as premium rates are based on previous
E

claims experience. Dr. Prathap Oburai, Director, National Insurance Academy, Pune
U
N

added that the surging claim cost was a matter of great worry for the insurance industry
IV

and if this trend is not reversed or contained it would queer the pitch for health insurance
E R

industry. In addition to this, experts from various field have expressed their views,
SI

suggestions and expectations in respect to health insurance. They expressed that product
TY

design, policy terms, conditions, insured profile - age, life style, domicile, culture and
health status are the main drivers of claim cost. They also came out with a solution how
to strengthen the claim process, by designing and implementing hospital package rates. In
respect to claims paid ratio, 83 per cent in 2003-04, 96 per cent in 2004-05, 91 per cent in
2005-06, 78 per cent in 2006-07 and 105 per cent in 2007-08. It shows that the claim paid
ratio increasing continuously except 2006-07. Seminar highlighted possible reasons for
 47

losses are, premium not commensurate to the risk covered, mis-use of health care supply
by stakeholders, increasing medical cost and absence of underwriting. Recent
developments in health insurance were also focused such as rejection cannot allowed on
arbitrary grounds or had made a claim in the previous year. Renewal notice covers
quantum of premium, it also includes note explaining such increase. In case of denial of
insurance to senior citizens, the reasons should be given in writing.

2.1.27 Mr. J. Hari Narayan, (2010) Chainnan, IRDA has expressed concern over the 'very low'
27
level of health penetration in the country . The situation, though, offers a great
opportunity for health insurers to grow in a substantial way. Chairman also expressed
that, of total health expenditure worth Rs.3 lakh crore, the spending on hospitalization
SA

accounts for Rs.1 lakh crore in the country. Against this, the existing level of health
insurance premium was worth only Rs.6,000 crore, which means that a majority section
VI
TR

of the Indian population does not have an insurance cover. This is a matter of great
IB

concern. In respect to standardization of policy wordings, Chairman stated that, the

AI

policy wordings can be improved upon by resorting to methods of rewriting or rephrasing

PH

which, he felt; will clear the ambiguity currently prevalent in the policy wordings. An
U

often ambiguity in policy writing is at the root of most disputes arising out of health
LE

insurance deals.
PU

2.1.28 Mr. J Hari Narayan, (2010) Chairman of IRDA, has critically opined that, the Third Party
N

Administrators (TP As) may phased out and insurance companies asked to handle the
E
U

business on their own as they are not delivery services and not performing as per customer
N

28
IV

satisfaction . Basically TPAs are appointed by insurers as middlemen to service

E

policyholders, process claims and pay hospital bills but the way the TPAs are running
R
SI

their business has posed a threat to the entire medical insurance sector. Almost 80% of
TY

the health insurance industry is facing a threat due to functioning of TP As. There were
also some information/facts reported that, hospitals sometimes decline to offer cashless
service if they don't trust TP As, couple of the insurance companies have already stopped
outsourcing their business of dealing with customers. The services provided by TPAs
include cashless service at hospitals, telephonic support to policyholders and management
of claims and reimbursement. Mr. Akshay Mehrotra, Head (Marketing), Bajaj Allianz
 48

mentioned that, we were the first in India to launch our in-house system instead of
depending on a third party. This way the customer can enjoy a seamless treatment
without much hassle.

2.1.29 Mr. R.G. Agarwala (2010) has mentioned in article that, our country's economic
condition will progress when our people have a healthy physique and a healthy mind29 .
The health insurance delivery system in India is at nascent stage. Though many
companies are offering plethora of health insurance products, the companies are bleeding
with huge claims. The reason is that people go for insurance once they suspect having
contracting any disease. Being individual it is a basic necessity and right of every person
and being insurance company having twin objectives of making profit as well as of
SA

providing service to society. Therefore, author has suggested to government, regulator

VI

and insurance companies to plan extensive media campaign to popularize the benefits of
TR

health insurance. A health insurance pool should be created in line of motor insurance
IB

pool to offset the losses in health insurance. Looking at the increased demands and size of
AI

health insurance industry a separate regulator may be instituted or a separate wing may be
PH

created within IR.DA to work exclusively. Grading of hospitals according to the facilities
U

available, changes, quality of the treatment provided so that before approaching the
LE

hospital people can have idea of changes.

PU

2.1.30 Mr. Alok Gupta (2010) has emphasized through article that, how underwriting has
N

significance impact in insurance30 .

E

It is the corner - stone for profitable insurance

U

business. Health insurance too requires certain pre-requisites for being profitable such as;
N
IV

unpredictability of loss which means sick persons can not buy insurance, measurability of
ER

loss and large number of similar risks. Underwriting is a process that an insurer applies to
SI

determine the desirability of acceptance of a risk, with defined terms, conditions and the
TY

commensurate adequate price. Health insurance underwriting essentially addresses the

risk of morbidity - the frequency and severity of it. Mr Gupta outlined that, with the
paucity of large and accurate sample data on morbidity in India, insurers face a tough
challenge in risk selection and adequate pricing of health insurance. He pointed out that,
health status, age, family medical history are important underwriting considerations.
Moral hazard throws up a serious issue for underwriting of health msurance, as
 49

occurrences of moral hazard relate to non disclosure of pre-existing conditions at the time
of buying health insurance. Use of genetic infonnation of individuals for health risk
assessment for underwriting of health insurance is a debate that presently engages the
insurers, the insuring public and the medical fraternity. The article also throws light on
underwriting of group health insurance. It requires analyzing the characteristics of the
group, its size, type of industry, eligible lives for coverage, composition of group in terms
of sex, age, income level of group members, employee turnover rate etc. If the above
mentioned information is made available to insurance companies then, they will remain
solvent at all times and in their business of covering risks, do not become a 'risk'
themselves.
SA

2.1.31 Mr. B.D. Banerjee, (2010) has made a substantial contribution in his article, that a large
population is away from health insurance, it makes a strong case for a potentiality of at
VI
TR

least 50 crore plus people to be under some health insurance schemes apart from
Government sponsored schemes for the weaker section31 .
IB

He also highlighted the

AI

composition of present market share as per 2007-08 for public sector companies is 62%
PH

and 3 8% of private sector companies. The author has broadly outlined the customers'
U

expectation as, there should be flexible and wide-ranging product without too many
LE

restrictions, all pre-existing diseases to be covered, domiciliary (non-hospitalization)

PU

treatment to be paid for, premium should be affordable, easy access to health care
N

facilities and nobody should be denied insurance cover irrespective of age of entry. Mr.
E

Banerjee also expects from regulator that, they should create a positive business
U
N

environment for health insurance products, clarifying the legislation and regulation of
IV

health insurance and co-ordinate health insurance with Government machinery to broaden
E R

the base.
SI
TY

2.1.32 Prof. Monika Mittal and Ms Pritagya Kawtra (2010) have published paper on micro health
insurance. The purpose was to explore how health insurance acts as a risk mitigating tool
especially for the poor who are characterized by low income, low capacity to pay
premium and most vulnerable to disabilities and illnesses. The paper has focused on the
demand and supply of micro insurance in India, as a basis for reducing the vulnerability of
poor and low-income people. The author has pointed out some constraints on demand side
 50

like, lack of formal insurance culture, risk perceptions and attitudes and on supply side the
issues like, the design of the program and its delivery. They also firmly believe that micro
insurance is a substitute solution for the vulnerable population when markets and the state
fail to provide risk management alternatives. Finally, it is concluded that people need to
join hands, build capabilities, create awareness, develop affordable and viable micro-
insurance schemes, build challenges towards the growth of the industry and fulfill our
dream of health India.

2.1.33 Mr. C.P. Udayachandran (2010) opens the debate with an article on products in the
domain of health insurance, in which he says that there is need for new products,
particularly long term in nature 33 . He asserts that the growth of the health insurance
SA

sector is dependent not only on the product quality but also on such factor like healthcare
VI

delivery, regulatory supervision and public perception. The author has a key question
TR

that, does the health sector have the product range and spread at its optimal level? If not,
IB

is there any possibility to improve the situation? Presently insurers are coming out with a
AI

variety of products within and without the traditional range. Stand alone health insurance
PH

companies with focused attention on health portfolio with long term health cover. Why
U

can there be no products, like in Personal Accident (PA), to pay disability compensation
LE

on the basis of percentage of disability. The author has also insisted on instead of making
PU

payment of premium for the entire 12 months, the mode can be six monthly, quarterly or
N

monthly options. The author firmly believes that, the healthy growth of the sector shall
E

not just depend on the products and marketing alone, which are matters internal to the
U
N

insurance domain. A lot shall also depend on peripheral regulations like the enforcement
IV

of standards of healthcare quality, provider accreditation, professional credentialing of

ER

healthcare providers etc. to give it the right mix of support and sustenance.
SI
TY

2.1.34 Mr. Anand Govindrajan (2010) has pointed out through the article that, Future Generali
India Insurance, ICICI Lombard, Cholamandalam MS General Insurance Co Ltd. and
Bajaj Allianz Insurance Co. have scrapped TPA tie up and set up their own team to handle
customer claims 34 . It is also pointed that, some doctors and hospitals have refused to
work with TPAs. Higher costs are not the sole reason why insurers are severing ties with
TPAs. The fact is the other three parties in the health insurance chain-insurers,
 51

policyholders and hospitals - are dissatisfied with the service levels of TP As. While
insurers accuse them of misusing funds provided for claims payment, hospitals complain
of delayed and short - settlement of bills and policyholders are angered by denial of
cashless treatment facility and reimbursement claims and even cases of bounded claim
cheques. Patients also face a lot of hassles in getting authorization letters from the TP A.
Hospitals also complain that TPAs take around 90 days to settle bills; often, they don't
pay the full amount, they are supposed to pay up within 30 days. But they don't.

2.1.35 Mr. Sukalp Sharma, (2010) has mentioned in his news reports about the storm happenings
in the health insurance sector that cashless card of four Public Sector Companies (PSU)
would not work at hospitals such as Max, Apollo, Ganga Ram, Escorts and other top
SA

private hospitals 35 . Instead, the individual has to pay for treatment and then seek a
VI

reimbursement from the insurance company. PSU companies have been incurring heavy
TR

losses due to inflated medical bills. Mr. Sukalp Sharma has complied opinions of many
IB

experts from IRDA, insurance companies, TPA and hospitals also on the line that,
AI

medical insurance grew eight-fold in the past decade mainly because of cashless cover
PH

and we talk of the health insurance sector as the sunrise sector and on the other, all of a
U

sudden policyholders are told that cashless facility will not be honoured. This is a
LE

violation of the consumer's right of choice. Consumers should have been informed in
PU

advance. But consumers were unknown to all this and hospitals are left to do the dirty job
N

of explaining the whole issue to the consumers and this will create a negative impact on
E

the reputation of health insurance business. It is not the insurance companies that are
U
N

being harsh on the consumers in any way. There has been a lot of mis-reporting on this
IV

issue. Some hospitals that are just focusing making money are the one exploiting the
ER

consumers. Insurance experts believe that the insurance companies were walking a
SI

tightrope and such a step was imminent. There are a lot of leaks in the health insurance
TY

system due to which the insurance companies lose a lot of revenue. IRDA says that, we
cannot really say anything on this matter as it is not a regulatory issue and it is a matter
between the insurance companies and the hospitals. Meanwhile, the hospitals also are in
no mood to back down. Policyholders are very much in trouble because of this crisis.
 52

2.1.36 Mr. Murali RK Iyer, (2010) has traced the evolution of the health insurance products in
India from time to time 36 . He has mentioned in his article that, there is tremendous
transformation, that both the demand and supply side. There is a growing disparity
between the availability of health care and its affordability. Author has listed some
challenges faced by insurers in the health insurance portfolio, like it is not a very
profitable portfolio as the loss ratio is high. There is a need to make a significant standard
of TP A. Underwriting nonns are not uniform. Medical services are not yet regulated
resulting in imbalance and lack of uniformity in operative and treatment procedure across
the country. As far as the opportunities are concerned, the entry of corporate sector in
health services has given new dimension of marketing of health products. There is a
general increase in awareness about health and general acceptance of the fact that
SA

"prevention is better than cure". Author has stated some possible innovation in health
VI

insurance products like LTC cover, income benefit/income loss health insurance cover,
TR

sum insured more than Rs.25 lakhs etc.

IB
AI

2.1.37 Dr. Chandirakala (2010) has mentioned in her article that, investments are the base of
PH

economic development and these investments are mostly the result of saving by public37 .
U

In this an insurance company plays a major role for the mobilization of such savings
LE

which are thereafter channelised into investment for economic growth. Insurance
PU

contributes a lot for economic growth and stability. Thus the development of insurance
N

sector becomes the highest priority in the economic and social policy of government. She
E

has also stated some challenges of insurance as due to illiteracy and lower level of
U
N

awareness, a large part of the population still away from the benefit of insurance. The
IV

complex terms and conditions add to the complication and results trouble to common
ER

people. Lack of skilled and trained professionals poses another big challenge. The Indian
SI

insurance industry takes various initiatives in order to raise its mark in the world market.
TY

First, it follows segmentation scheme for marketing. Second, it enlightens the customers
in order to bring awareness regarding products, services and pricing. The third initiative
is product innovation. The author has concluded that, modernization with cost cutting can
definitely boost up the benefit not only for the insurance sector but also for the economy
of India as a whole.
 53

2.1.38 Mrs. Gunita Arun Chandhok (2010) has conducted a survey in Thiruvallur District of
Tamilnadu to find out the awareness level of health insurance among the rural poor and
the impact of this insurance on their financial lives 38 . The survey conducted among those
respondents whose income did not exceed Rs.1,500 per month. The sample size
comprised of 50 households, covering a population of 196 respondents. It is mentioned
that, 96.4% of respondents are aware of health insurance and 47% respondents are willing
to pay Rs. 85 per month towards health insurance premium. The author has stated that,
health insurance should be viewed more as a social perspective than a business motive.
Health and economic development are closely inter related and it is difficult to achieve
one without the other. It is also pointed out that, India is the fourth largest producer of
drugs by volume in the world and is among the largest exporter of drugs in the world. It
SA

is concluded that, the result indicates huge market untapped for health insurance m
VI

Thuruvallur District. An effective service mix and distribution strategy can be

TR

implemented to tap the rural market. By doing this, rural poor will lead a secure and
IB

peaceful life.
AI
PH

2.1.39 Union Health Ministry, Government of India (2010) is planning to protect the rights of
U

persons suffering from mental illness 39 . At present, no health insurance company cover
LE

any mental illness, psychosomatic dysfunction or problems connected to psychiatric

PU

conditions, personality disorders or mind, even if it is caused or aggravated by accident.

N

The Government has also acknowledged that the previous law, Mental Health Act (MHA)
E

1987, failed to protect the rights of mentally ill persons. The updated, amended and
U
N

comprehensive law is more rights based. It has indicated as a growing problem, as per the
IV

data from WHO' s Mental Health GAP Action Programme that, 200 people out of
E R

1,00,000 in India suffer from schizophrenia and bi-polar disorder, while there in 10,000
SI

experience an episode of acute psychosis every year. Additionally, over one percent of
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people have severe mental disorders. The ministry of health and family welfare estimates
that 6-7% of India' s population suffers from a mental disorder. It estimates, about 25% of
mentally ill people are homeless. In such cases, the draft Act prescribes that, the
government will provide for halfway homes, group homes etc. for persons who no longer
require treatment in a more restrictive mental health facility.
 54

2.1.40 Government of India (2011) has declared health insurance cover up to Rs.30, 000/- for
domestic workers from 2011-12. It will be available in any empanelled hospital in the
country and annual premium of Rs.750/- will be borne by government and scheme is
operated by Rashtriya Swasthy Bima Yojna (RSBY) with the help of union government40 .
Domestic workers in the age group 18 - 59 years are eligible and the premium will be be
shared by the Central and State Government in the ratio of 75:25 Domestic workers
which forms one of the largest sector of female employment in the urban areas, has
remained unregulated and unprotected by labour laws. These workers usually stay in
urban slums, where unhygienic environments, lack of basic sanitary facilities, unsafe
drinking water prevail. This makes them prone to various diseases and infections.
Therefore, allowing health insurance cover to such poor, vulnerable, illiterate and
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unskilled class is a definitely welcome move by government. As far as the enrollment

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concerned, the beneficiaries will have to get identification certificates from two of the
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four eligible institutions; employer, residents' welfare association, registered trade union
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or the local police and then smart card will be issued by RSBY. The scheme is expected
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to cost the Centre around Rs.30 crore during 2011-12 with the spending projected to rise
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to over Rs. 74 crore in the next financial year.

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2.2 RESEARCH METHODOLOGY

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2.2.1 INTRODUCTION:
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Research as a process involves defining and redefining problems, hypothesis formulation,

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organizing and evaluating data, deriving deductions, inferences and conclusions, after
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careful testing. Research, as defined by Kerlinger, is a systematic, controlled, empirical

and critical investigation of hypothetical propositions about the presumed relationships
among natural phenomenon. At times research focuses itself on descriptive rather than
on causal or experimental aspects. In a complex research or study, researcher need to
understand how identify information and to find out the emerging problem to make
prompt and effective decision making. Research refers to a critical and exhaustive
 55

investigation of experimentation having as its aim the revision of accepted conclusions in

the light of new discovered facts. The word ' methodology' is the combination of two
words ' method' which implies ' study'. Thus, 'methodology' implies 'a systematic way of
studying something' 41 . It includes all those methods and techniques that are used for
conducting a research. According to C.R. Kothari, research methodology is, 'when we
talk of research methodology we not only talk of the research methods but also considers
the logic behind the methods we use in the context of our research study and explains
why we are using a particular method or technique and why we are not using others so
that research results are capable of being evaluated either by the researcher himself or by
others' .
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2.2.2 TYPE OF RESEARCH:

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This researcher has adopted 'descriptive research' methodology. The study is carried out
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with specific objectives and it narrates facts of health insurance policyholders, non
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policyholders, general insurance companies, TPAs as well as hospitals. The study is

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based on survey of four different segments. This research tries to describe the
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characteristics of the respondents in relation to health insurance as a product. In this

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study, the degree of use of the product to different types of respondents is of great
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importance.
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2.2.3 STATEMENT OF THE PROBLEM:

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Health being one of the largest industries in the world, with a global turnover of 2.75
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trillion, but its negligence in India is quite disappointing. It is quite disheartening to find
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our 'mera Bharat mahan' in the l 121h position among the 119 nations covered under a
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study by World Health Organization in its world health report. The increasing economic
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growth, ageing population and weak social security and pension system that exposes a
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great majority of the work force to old age insecurity, calls for insurance coverage against
ill-health at affordable prices. Further, with more and more nuclear families becoming
the rule, there will be a great demand for insuring the "bread-winner" of the family
against ill-health. Secondly, it is being increasingly felt that conventional reimbursement
type of health systems are unlikely to be effective in India where consumers have limited
ability to pay premiums upfront. A need has therefore arisen for an innovative approach
 56

to structure policies and premmm that integrates both financing and delivery of
healthcare, that too, at an affordable price.

While teaching students, the researcher came to know that, there is a need to create
awareness among people about the importance of health insurance. Researcher has also
noticed in some seminars and discussions that, competition, whether in banking or
insurance, has seen the consumer finally gaining with a variety of products available at
doorstep and lower cost of products over defined period. The same push needs to be
provided to health insurance.

2.2.4 OBJECTIVES OF THE STUDY:

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The above statement of problems and discussion with guide has helped researcher to set
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the objectives of study as:

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1. To study the features of health insurance schemes offered by Public, Private

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General insurance companies, Standalone Company, Local bodies (PMC) and

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Non-government organization (NGO).

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2. To assess the beneficiaries holding health insurance scheme and also the
perceptions of non policy holders.
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3. To identify the socio-economic factors that influences the demand for health
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insurance policies.
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4. To study the role of Government, Insurance Regulatory & Development

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Authority of India (IRDA), and Third Party Administrators (TPA) in the

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development of health insurance business.

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5. To study the organization and management of selected general msurance

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companies and hospitals.

6. To analyze the demographic transition and progress of health sector in the
context of Indian economy.
 57

2.2.5 RESEARCH HYPOTHESES:

The formulation of hypotheses has gone hand in hand with the selection of a research
problem. Following hypotheses are formulated for this study:

1. Socio-economic factors such as age, gender, education, number of family

members, monthly income and having health insurance policy are independent.
2. Awareness of health insurance in lower income group is significantly low in
Pune.
3. Since privatization of the general insurance sector, there is a growth of health
insurance in India.
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2.2.6 SAMPLE DESIGN:

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In order to study the economics of health insurance scheme; General Insurance

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comparues, Health insurance Policyholders, Non policyholders, Third Party

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Administrators and Hospitals are surveyed.

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2.2.6.1 Pilot survey: In order to get appropriate result of the objectives and hypotheses
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of study, the researcher conducted pilot survey. For this purpose, 10 health
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insurance policyholders and 10 non policyholders were surveyed. From these

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individuals questionnaires were filled up and data was collected. Thereafter

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necessary corrections were made and questionnaires finalized.

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2.2.6.2 Types of universe, sample design and size: The researcher has constituted
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samples as follows:
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1. General Insurance Companies

2. Health insurance Policy holders and Non policy holders
3. TPA
2.2.6.3 Multi stage sampling (First stage): There were 23 General Insurance
Companies during survey year of 2010-11. Researcher contacted all 23 general
insurance companies but only 6 companies responded to the questionnaire.
 58

Others have expressed inability to give information. Therefore, out of the

universe of 23 General Insurance Companies the following 6 companies were
selected and hence constituted a sample.

1. Bharati Axa General Insurance Company Ltd. (Private sector)

2. National Insurance Company Ltd. (Public sector)
3. Cholamandalam General Insurance (Private sector)
4. The Oriental Insurance Company Ltd. (Public sector)
5. Star Health and Allied Insurance Company Ltd. (Private sector -
standalone)
6. The New India Assurance Company Ltd. (Public sector)
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2.2.6.4 Second stage: In respect to health insurance policyholders of the above

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selected companies it was observed and Pune based health insurance policy
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holders are considered according to sum insured slabs and such 10 slabs were
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identified as Rs.50,000/-, Rs.1,00,000/- , Rs.1,50,000/-, Rs.2,00,000/-,

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Rs.2,50,000/-, Rs.3,00,000/-, Rs.3,50,000/-, Rs.4,00,000/-, Rs.4,50,000/-

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Rs.5 ,00,000/- By applying Stratified random sampling it was decided to have an

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equal sample of 5 insured persons from each slab per company. Thus from one
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company a sample of 50 insured persons collected and accordingly from 6

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companies a total sample of 300 policyholders was formed.

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2.2.6.5 Non policy holders: For collecting the data from non policyholders, it
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was decided to contact the persons from different educational institutes, banks,
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offices, and neighbours etc. which are not having health insurance policy and
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ready to give information. 30 lakhs is the population of Pune city in the survey
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year of 2010-11. Statistically a sample of 384 is sufficient for 95 per cent

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confidence level. Researcher attempted to achieve this sample size however; he

could get the response from only 300. This sample size is also sufficient
considering the large universe of non policyholders.

2.2.6.6 Third Party Administrators (TPA): There are 27 TPAs out of these; 3
TPAs expressed willingness to impart data and information. Hence conveniently
these 3 were taken for collection of data.
 59

2.2.6. 7 Hospitals: Out of 300 surveyed health insurance policyholders, it is found that
55 respondents had taken treatment and claimed the amount. These 55
respondents had taken treatment in different 9 Pune based hospitals and
accordingly the data collected from these hospitals.

2.2.7 DATA COLLECTION:

The study is based on both primary and secondary data. Five types of questionnaires
were prepared to collect data from the health insurance policyholders and non
policyholders. Three hundred individuals were surveyed from each category. Thus total
600 individuals were surveyed to collect primary data. Data pertaining to age, gender,
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education, number of family members, occupation, income, premium amount, medical

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expenses etc. is collected. In the beginning a pilot survey was conducted by surveying 10
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health insurance policyholders and 10 non policyholders. Then the main survey was
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conducted by applying Stratified Random Sampling method.

AI
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Separate questionnaire was prepared to collect data from General Insurance companies
who are involved in health insurance business. Out of 23 insurance companies 6
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companies agreed to provide the required data.

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Fourth questionnaire was prepared to get information from Third Party Administrators.
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There are 27 TPAs but only 3 companies have provided information after many visits.
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Fifth questionnaire was prepared to collect data from Hospitals which plays service
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provider role. The information pertaining to available number of doctors, nurses, number
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of beds etc. are collected.

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In order to study the problem as per the objectives and hypotheses, the researcher has
adopted data collection approach as follows:

2.2.7.1 Primary data: Some deficiencies were reported during pilot survey accordingly
corrections were incorporated and final questionnaire prepared. Questionnaire
was prepared as per the objectives and hypotheses of the study and accordingly
 60

the survey of individual respondents, general insurance companies, TPAs and

hospitals conducted in Pune city. Questions pertaining to open and close-ended
used for these survey. In addition to this, researcher conducted focused interview
with 55 claimed health insurance policyholders in order to explore reasons/issues
involved in claim settlement. The data collection process has taken about 7 to 8
months of time.
2.2. 7.2 Secondary data: Information pertaining to number of Health Schemes initiated
by Government, Crude Birth Rate, Crude Death Rate, Infant Mortality Rate, Life
expectancy etc. is collected from different journals, magazines, books and related
websites. Researcher has also attended and presented papers in various seminar
and conference which has helped a lot in data collection as well as updating of
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knowledge. The information available with general insurance companies,

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statistics from the IRDA, trade associations and other non-governmental

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development agencies is also collected. References are collected from the library
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of National Insurance Academy, Pune and other institutes. Percentages and

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growth rates are used as statistical tools to analyze the collected data. All these
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collected data is tabulated and used for report writing.

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2.2.8 TABULATION AND EXECUTION OF DATA:

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Data collected through primary source is executed by way of coding, sorted out and fed
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into excel sheet in computer for drawing of statistical inferences. In first stage each raw
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data was given a code as per the purpose of study and subsequently it was edited to get
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quality data. After receiving values through excel, the same data used for getting of pie,
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bar chart, histogram and tables. Data collected through secondary source used for
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preparation of table and calculation of growth in percentage form.

 61

2.2.9 TESTING OF HYPOTHESES:

The most important step in the process of research is that of testing the formulated
hypotheses. Researcher has tested the validity of the formulated hypotheses by applying
' chi-square test'. It is an important non-parametric test and as such no rigid assumptions
are necessary42 . As a test of independence of attributes, x2 test enables to explain whether
or not two attributes are associated. If the calculated value of x2 is less than the table
value at a 5% level of significance, it is concluded that null hypothesis stands (null
hypothesis accepted) which means that the two attributes are independent or not
associated. But if the calculated value of x2 is greater than its table value then null
hypothesis does not hold good means it is rejected. Important characteristic of x2 test are,
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this test as a non-parametric test is based on frequencies and not on the parameters like
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mean and deviation. It is useful for testing the hypothesis and is not useful for
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estimation. It is calculated as follows:

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x2 = (0 ij-E ij) 2
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~ -----------------
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E ij
Where
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0 = observed frequency of the cell in ith row andjth column.

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E = expected frequency of the cell in ith row and jth column.

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Accordingly, the results derived by applying chi-square tests are mentioned in data
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analysis chapter no. V.

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2.2.10 SCOPE OF THE STUDY:

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The entire study is restricted to Pune city only therefore, beneficiaries from the Pune city
selected for survey. The reason for why the Pune has been chosen as a representative
study is that Pune, being a major city in the state of Maharashtra, in view of the business
development considered it is an ideal city for public and private growth in Health
Insurance since a large number of multinational corporations and most Indian major
 62

comparues have established offices in this city. Most maJor banks and financial
institutions also have branches in Pune. Therefore, large number of job opportunities is
available to youngsters as well as experienced personnel. Public insurance companies
have regional offices as well as many branches in this city. Almost all private insurance
firms have opened offices and started business operations in Pune. Most of the TPAs
have opened branch office in Pune. Due to growing population in Pune, existing
hospitals have expanded with multi specialty facilities and many new more hospitals have
established recently.

Researcher has observed the following levels of urbanization; in terms of the rate of
urbanization, regional growth and equality of Maharashtra State and Pune city.
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About Maharashtra: As per the 2001 Census, about 27.8% of the population
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lives in urban areas. Till 1991, Maharshtra was the most urbanized state among the 16
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large states oflndia44 . In 200 1, with regard to the urban population, Maharashtra ranked
IB

second, with a share of 42.4% next to Tamil Nadu with a share of 43.9% yet in absolute
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terms, Maharashtra's 41 million of urban population far exceeded Tamil Nadu's 27

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million. These two states are closer to the extent of urbanization than India.
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Table 2.2.1
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Levels of urbanization(%) by Census Divisions and Re2ions, Maharashtra: 1981-2001

Census Division/Region 1981 1991 2001
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(1) Konkan Division 66.4 71.6 75.l

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(2) Nashik Division 22.1 25.6 28.2

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(3) Pune Division 30.5 32.3 37.5

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(I) Rest of Maharashtra Region (ROM) 42.4 46.2 50.5

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( 4) Aurangabad Division/ (II) Marathwada Region 18.6 21.9 24.6

(5) Amravati Division 22.2 25.0 26.5

(6) Nagpur Division 29.7 35.0 37.1

(III) Vidarbha Region 25.9 30.2 32.2

Source: Director of Census Operations, Maharashtra 1981and2001.
 63

According to the United Nations (1995), 45% of the world population lived in cities in
the mid 1990s. Maharashtra is the second largest state in India both in terms of
population and geographical area (3.08 lakh sq. km.). The State has a population of
around 10 crore (2001 Census) which is 9. 4 per cent of the total population of India.

Regional growth and equality:

For census purposes, Maharashtra State is divided into six divisions i.e. Konkan, N ashik,
Pune, Aurangabad, Amravati and Nagpur. These six divisions, for administrative
purposes are grouped into three regions, the first three divisions, form rest of Maharashtra
(ROM) region, Aurangabad forms Marathwada while the last two together form Vidarbha
regions. Above table shows that Rest of Maharashtra (ROM) was the most urbanized
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region of the state, Vidarbha was in the second while Marathwada held the third place in
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all the three census years. Within ROM Region, Konkan, which includes Mumbai,
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Thane and Raigad was the most urbanized division. Nearly 66% of Konkan division's
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population in 1981 and 75% of it in 2001 lived in urban areas. Pune division was
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relatively less urbanized than Konkan while Nashik was the least urbanized of the three
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divisions of ROM. Of these three, Pune experienced the fastest growth of urban
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population in the 1990s. Hence Pune city is selected for this study.
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2.2.11 CHAPTER SCHEME:

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Chapter I: This chapter devoted for the overview of health insurance in India and other
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part of the world. Researcher has highlighted historical background right from
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economics of Arya Chanakya till mediclaim. Global view of Health care management of
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various 16 countries which belongs to developed, developing as well as underdeveloped

nations have been referred and mentioned in this chapter. India has witnessed to various
phases of insurance development in the form of Employee State Insurance (ESI), Central
Government Health Schemes (CGHS) and also health schemes and facilities
implemented by ministries like Defense and Railway. International comparison is also
mentioned followed by observations. Finally the chapter ends with the economic
 64

overview of health insurance, influential factors of health insurance and factors which
affects on health insurance consumption are also mentioned in this chapter.

Chapter II: This chapter conducts a review of literature and to explain research
methodology. Researcher has conducted a detailed review of literature under the
instruction of Guide. Total 40 references pertaining to periodicals, journals, magazines,
research papers, research theses, newspapers and seminar/conferences have been
collected and mentioned in this chapter. The next sub part of this chapter is research
methodology, wherein type of research, statement of problem, objectives, hypotheses,
sample design, procedure of data collection, tabulation, statistical tools for hypotheses
testing and scope of the study as well as the justification as to why Pune city is chosen for
SA

survey is being mentioned. At the end, chapter scheme in brief is also provided.
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Chapter III: This chapter dealt with the features of different health insurance schemes
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offered by companies, local bodies and NGOs. Total 6 general insurance companies
IB

belonging to public, private and standalone companies have been mentioned. Though
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there are total 23 companies till 2011 , but only 6 companies' product have discussed as a
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representative base. Company' s profile, products, features, exclusions etc. are covered.
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Apart from this, health schemes implemented through local body i.e. Pune Municipal
Corporation for waste pickers and Non Government Organization (NGO) like Annapurna
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Parivar Vikas Savardhan, Pune, based are also mentioned. At the end, economics of
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these schemes in respect to various factors like target population, type of risk, subsidy
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back up, scope and amount of benefits to person are also provided in this chapter.
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Chapter IV: This chapter narrates the policy, role and responsibilities of Central
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Government, Insurance Regulatory & Development Authority (IRDA), Third Party

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Administrators (TP As) and hospitals in respect of health. These are the mam
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stakeholders involved in health insurance business apart from end user that is health
insurance policy holders. Therefore, it is necessary to study and understand the role of
each stakeholder. Some of them have been playing role from long time, few of them
functioning recently. Since this study is meant for Pune city, therefore a glance not only
from the point of view Pune but India as well as Maharashtra State's development in
respect of health is also mentioned.
 65

Chapter V: This chapter covers data analysis based on the questionnaire prepared for
four different segments followed by hypotheses testing as mentioned in the research
methodology. It has covered demographic data, benefits offered, claim settlement issues,
problems associated with issue and expectations. The data is presented by using tables,
graphs, percentage in growth and statistical tools are also used for hypotheses testing.
Data from primary as well as secondary has been used for this chapter.

Chapter VI: This chapter concludes with findings, suggestions and conclusions.
Researcher has referred data analysis for writing of findings and suggestions which are
based on the filled questionnaire from individual respondents, general msurance
companies, TPA, hospitals as well as some of the suggestions are also based on
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observation. Finally the chapter ends with conclusion drawn from the data analysis.
VI
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REFERENCES
AI
PH

1. Garg Cham C, Paper on 'Equity of health sector financing and delivery in India',
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2. Gupta Indrani, Paper on 'Private health insurance and the willingness to avoid
PU

health costs: a result from Delhi study, (2000), page no.3, 7 & 29.
3. Malavankar Dileep and Bhat Ramesh, Paper on 'Health Insurance in India:
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E

Opportunities, challenges and concerns', IIM Ahemedabad (Nov 2000), page 3 & 15
U

4. Kutty Shashidharan K., Ph.D. thesis on Life insurance as a financial product, (Nov
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2000), National Insurance Academy, Pune.

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5. Wadikar Ashok Laxman, Ph.D. thesis on Innovativeness in the insurance industry,

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(Jan 2001), INDSEARCH, Pune.

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6. Kumar KBS, 'Health insurance in India: an introspection', Insurance Chronicle

(ICF AI) journal (Feb. 2002), page no.1 & 3.
7. Kumar KBS, 'Indian health care: A piped off dream', Insurance Chronicle (ICFAI)
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8. Murty GRK, 'Healthcare msurance: New business opportunities for banks',
Insurance Chronicle (ICFAI)joumal (Dec 2002), page 1 & 5.
 66

9. Deshpande S.P., Ph.D. thesis on Health Insurance, (2003), University of Pune.

10. Mony Sankara V., 'Health Insurance - Why is not growing?', Forte Insurance journal
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11. Lohia Yogesh, 'Health Insurance', Forte Insurance journal (Sep 2004), page 39, 40
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12. Parekh Nimish R., 'The progress of Health Insurance in India', Forte Insurance
journal (Sep 2004), page 30, 31, 32 & 33.
13. Kuruvilla Sarosh and team, report on 'The Karnataka Yeshasvini Health Insurance
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14. Ahuja Rajeev and Narang Alka, 'Emerging trends in health insurance for lower
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income group', Economic & Politically weekly (Sep 2005), Vol. XL No38, page
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4151.
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15. Kumar,Praveen 'Health Insurance in India', The Management Accountant (Dec

IB

2005), Vol. 40 No. 12, page 939, 940 & 946.

AI

16. Bhasin Sampa, 'Health Insurance: An imperative', Insurance Chronicle ICFAI

PH

journal (Jan 2006).

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17. Thomas George E., Ph. D. thesis on Managing change in the general insurance
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2006), National Insurance Academy, Pune.

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18. Dror David M., 'Health insurance for the poor: myths and realities', Economics and
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Politically Weekly, (Nov 2006), page 4541-44.

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19. Bhat Ramesh and Jain Nishant, paper on 'A study of factors affecting the renewal of
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health insurance policy, IIM Ahmedabad (Jan 2007), page 3.

SI

20. Alex George, 'Critical appraisal of micro health insurance laws', Economic and
TY

Politically Weekly, (Feb 2007), page 476-479.

21. Editorial article in daily English newspaper 'Maharashtra Herald' Pune, dated 12
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22. Shivdasni Mukesh, 'The future of health covers', Outlook Money, (May 2007), page
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 67

23. A week programme at National Insurance Academy, Pune on 'Health Insurance

Management-Non life', during 20-25 August, 2007.
24. Daily English newspaper 'The Maharashtra Herald' Pune dated 6 May, 2008.
25. Thomas George E., 'The Indian TPA system- Enjoy, Mend, End or Endure it, but
evaluate it first', Journal of Insurance Risk Management-Pravartak, (Vol. IV Issue 6
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26. Seminar on 'Health insurance and care', jointly organized by National Insurance
Academy, Pune and Institute of Actuaries of India, during 7-8 January, 2010 at Pune.
27. Daily English newspaper' Times ofIndia' Pune dated 8 January, 2010, page 4.
28. Daily English newspaper ' DNA' dated 8 January, 2010, page 1.
29. Agarwala R.G., 'Proposed development in health insurance sector in India', The
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Insurance Times, Vol. XXX No.2 (Feb 2010), page 18 & 19.
VI

30. Gupta Alok, 'Smothering moral hazard - underwriting in health insurance', !RDA
TR

Journal, Vol. VIII No.3 (March 2010), page 18-22.

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31. Banerjee B.D., 'Health insurance - Issues, challenges and way forward' , The
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Insurance Times, Vol. XXX No.3 (March 2010), page 40-44.

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32. Mittal Monika and Kawtra Pratigya, 'Micro health insurance: A risk mitigation
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strategy for poor', Proceedings of national seminar jointly organized by Medi-caps

Management Institute, Indore (MP) and LIC, during 22-23 April, 2010, page 66-70.
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33. Udayachandran C.P., 'Need for variety in product - Indian health insurance sector',
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!RDA Journal, Vol. VIII No.4 (April 2010), page 10-13.

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34. Govindrajan Anand, 'Why health insurers are doing away with third-party
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administrators', Moneylife, Vol.5, Issue 6 (7-20 May 2010), page 12 & 14.
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35. Daily English newspaper 'The Financial Express', dated 18 July 2010, page 4.
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36. Iyer Murali RK, 'Evolution of health insurance products in the Indian non-life
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insurance market', Bimquest, Vol. 10, Issue 2 (July 2010), page 57-74.
37. Chandirkala,S. 'The role of insurance sector in Indian economic growth', Pravartak,
Vol. V, Issue 2 (April-September 2010), page 28-31.
38. Chandhok Gunita Arnn, 'Health insurance for the rural poor in India', Pravartak,
Vol. V, Issue 2 (April-September 2010), page 32-34.
39. Daily English newspaper "DNA" dated 27 December, 2010.
 68

40. Daily English newspaper "Times ofIndia" dated 24 June, 2011.

41. Sarangi Prashant, Research Methodology, Taxmann Publication (P) Ltd., (September,
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42. Kothari C.R., Research Methodology, New Delhi, New Age International (P)
Limited, 2004, page no. 236, 237 & 250.
43. Bishop, Yvonne M.M., Fienberg, S.E. and Holland, P.W. 1975. Discrete multivariate
analysis: Theory and practice. Cambridge, MA: The MIT Press.
44. Maharashtra Development Report, Planning Commission, Government of India, New
Delhi. , (2007), page 321-325.
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