Above: IRDA’s new proposal will offer discounts to insurers following a healthy lifestyle which includes doing yoga regularly/Photo: UNI

Domestic insurance companies need to promote treatments which reduce dependence on modern drugs and investigations. International insurance companies reduce premiums if you are a non-smoker or have quit smoking

Health insurance holders are likely to get more wellness and preventive features, including Outpatient Department (OPD) consultations or treatments, pharmaceuticals, health check-ups and diagnostics, and discount vouchers in gyms and yoga centres in a policy package as part of the draft guidelines being framed by the Insurance Regulatory and Development Authority (IRDA).

Some insurance companies have reduced premiums and are offering discount coupons to clients who join gyms, quit smoking or live a healthy lifestyle, including doing regular yoga. The idea is to reduce hospital admissions and severity of diseases.

The services proposed include “outpatient consultations or treatments, pharmaceuticals, health check-ups/diagnostics”, including discounts on these services by redeemable vouchers. However, these open and direct incentives to policy holders will also need strict monitoring in order to prevent unhealthy competition and misuse.

Health insurance works on the principle of statistics. The larger the number of people who get insured, the greater is the viability of any insurance set-up. Insurance premiums are also decided on the vital statistics of a country. For instance, in a population of 1.3 crore in Delhi, 250 deaths occur every day. That is taken into account along with the number of beds available in Delhi, including bed occupancy and the average stay of a patient in a hospital. Nowadays, most insurance coverage reimburses hospitals and doctors based on the principle of DRG (Disease Related Groups). In this, similar disease patterns get reimbursement.

Take Ayushman Bharat Yojana. On paper it says that it covers a family for up to Rs 5 lakh per annum. But this is not true. Most treatment packages are capped. For a family to spend Rs 5 lakh a year will, probably, require all five members of the family getting admitted multiple times a year.

The average payout of an admission in Ayushman Bharat Yojana is only Rs 20,000. Packages which provide Rs 1 lakh for treatment are for uncommon diseases that afflict once in a lifetime, for example a heart bypass.

Internationally, OPDs are covered under yearly insurance but with a rider. They do not cover dental treatments, and drug prescriptions are with co-pay (a fixed amount for a covered service paid by a patient to the provider of service before receiving the service). Whenever there is co-pay, the chances of misuse of insurance policy is low.

The Medical Council of India’s ethics regulation 7.7 can cancel the licence of a doctor if he or she is involved in creating any document which amounts to fraud. Registered medical practitioners are in certain cases bound by law to give certificates, notifications, reports and other documents signed by them in their professional capacity for subsequent use in courts or for administrative purposes. Any registered practitioner who is shown to have signed any such document which is untrue, misleading or improper, is liable to have his or her name deleted from the register. Similarly, under Indian Penal Code 193, there is a punishment of up to seven years for issuing fabricated documents along with a fine.

Considering all this, some key steps need to be taken to reduce the number of people seeking treatment in hospitals.

• LIC, the single biggest insurer in the country, should join some other companies in promoting wellness and awareness about emergency life-saving measures like cardiopulmonary resuscitation or CPR.
• IRDA should promote hospitals which have wellness centres and also promote yoga and meditation. All efforts should be made by them to promote treatments which reduce dependence on modern drugs and investigations.
• Insurance companies should reduce premiums for those people who are fully vaccinated. They should also bargain with companies to provide vaccinations at a discount.
• Insurance companies should also promote annual health check-ups so that diseases are diagnosed much earlier, leading to less expensive treatment. Instead of reducing premiums, many companies provide free check-ups annually for every three years.
• IRDA needs to promote a one-drug-one-company-one-price policy. Over 80 percent of the cost of treatment comes from drugs and devices. The cost of the same medicine may differ with the same company marketing the drug under three different brand names. DCGI, the Indian drug regulator, does not differentiate between generic-generic, generic-trade and generic-branded drugs.
• IRDA should also reimburse only drugs, devices, diagnostics, reagents and equipment on the national list of essential medicines. Currently, only some drugs and devices are included. Reimbursement for laboratory investigations is currently in the planning stage.
• Any investigation or drug given from the non-NLEM list must have a justification from the hospital or the doctor.
• Insurance companies like Medicare in the US must also directly communicate with doctors in India. US Medicare has a weekly newsletter by which they update knowledge of doctors with the latest treatments as per the prescribed guidelines.

Dr KK Aggarwal

Padma Shri Awardee

President Confederation of Medical Associations in Asia and Oceania (CMAAO)

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Past National President IMA