SABU LAMA

UNIT 3-HEALTH INSURANCE

1. What is health insurance? Explain about the significant factor of health insurance.
Health insurance is that type of insurance that provides protection against
catastrophic medical expenses.
The significant factor of health insurance are as follows:
 Age: Old people are more prone to get affected by diseases than younger
ones. Thus, old people are more likely to get health insurance. From the
viewpoint of insurance companies, their ideal customer are younger ones
and are certainly accepted.
 Gender: Human bodies are structured both physically and biologically
differently. Both gender male and female have different level of immunity.
Similarly, based on their working nature and activities, female
counterparts are likely to get health insurance.
 Family History: Health insurance companies may consider a person family
history when underwriting or assessing their risk. Some health insurance
plans may provide coverage for preventive care services based on family
history.
 Mortality rate: Mortality rate can be an indicator of overall health status
and the likelihood of an individual requiring medial care when assessing
health care insurance.
 Amount of insurance: The amount of insurance refers to the maximum
amount that an insurance company will pay for for medical expenses
incurred by the insured individual.
 Occupation: Occupation can be factor that insurance companies considers
when assessing risk and setting premiums. An individual’s occupation can
impact their health and the likelihood of them needing medical care.
 These are just some factors that can affect health insurance. Some other
factors can be gender, consumption of alcohol, use of cigarette, level of
exercise, time period etc.

2. Mention the objectives of health insurance.

The objectives of health insurance are as follows:
 Security against financial burden
 Better health care management
 Regular health care checkup
 No additional fund required
 Social security
 Peace of mind
 Increasing efficiency

3. Explain about the benefits of insurance coverage. Explain the importance of

health insurance in context of Nepal.
Health insurance is a type of insurance coverage that helps to pay for medical and
health care expenses such as doctor’s visits, prescription, medications,
hospitalization and emergency medical services.
Some of the benefits of health insurance are as follows:
 Access to health care: Health insurance provides access to necessary
medical care when it is needed without worrying about the financial cost
of the treatment.
 Financial protection: Health insurance protects from financial risks
associated with expensive medical risk associated with expense medical
bills. It can help to pay for preventive care services that can avoid costly
medical treatments in the future.
  Peace of mind: Health insurance provides with peace of mind knowing
that all medical expenses are taken care of in case of medical emergency
or unexpected illness.

 Preventive care: Health insurance plans often covers preventive care

services such as annual checkups, screening and vaccines preventive care
can help catch health problems early and avoid more serious medical
conditions in the future.

 Improved health outcomes: People with health insurance are more likely
to receive preventive care leading to better health outcomes. Health
insurance also helps ensure that there is access to necessary treatments and
medications, which will improve overall health and well beings.

Health insurance is becoming increasing important in Nepal due to the following reasons:

 Increasing health care costs: Health care costs are rising rapidly in Nepal, making
it difficult for people to afford necessary medical treatments. Health insurance can
help individuals and families cover the cost of medical expenses.
 Limited public health infrastructure: Nepal’s public health care infrastructure is
limited and many people have to travel to cities for specialized medical care.
Health insurance can provide access to quality health care facilities and providers
across the country.
 Government initiatives: The government of Nepal has introduced several
initiatives to promote health insurance in the country. For example, the
government has launched the National Health Insurance program which aims to
provide health insurance coverage to all citizens.
 Reduced financial burden: Health insurance can reduce the financial burden on
individuals and families especially in case of unexpected medical emergencies or
serious illness.
 Mental health coverage: Mental health is often neglected in Nepal due to social
stigma and lack of awareness. Health insurance can provide coverage for mental
health services including therapy and counseling.
 Employer benefits: Many employers in Nepal offer health insurance as a part of
their employee benefits package which can be a valuable recruitments and
retentions too.
In conclusion, health insurance can provide financial protection and access to
quality health care, which is essential for improving health outcomes and
wellbeings.

4. Explain about the types of health insurance.

Health insurance is a type of insurance coverage that pays for medical and
surgical expenses incurred by an insured person.
There are several types of health insurance are as follows:
 Individual health insurance: It is a type of health insurance policy that
provides medical and health care coverage for an individual person or
family rather than a group of people. It is typically purchased by
individuals who do not have access to group health insurance coverage
through their employer or other organizations.
 Group health insurance: The set of two or more individual having
common interest and goals. It is that type of health insurance which
provides protection against catastrophic medical expense of a group. One
group is bounded with one insurance policy. The benefits are power,
security, opportunities, network, and collective bargaining.
 Social health insurance: It is a type of program initiated by government for
people who is suffering from long term durable diseases. It is a program
designed to provide financial support to needy people like old age,
medicare facility, disable people, unemployed people, workers
compensations etc.
The benefits are financial support to needy people, treatment of long term
durable diseases, insurance premium is very low.
  Commercial health insurance: It is sellable in the market by using
insurance intermediaries like as agent, brokers, TPA for generating profit
by the insurance company.
 Advantage to customer: less exploitation, product at convenient
place and saves time.
 Advantage to company: higher profit margin, increase market
coverage
 Disadvantage to customer: price burden to people, exaggerating
information
 Disadvantage to company: high competition, change in taste and
preferences.
 Micro health insurance: It is a type of health insurance that provides
protection against catastrophic medical expenses to the low income
people. Those people who are suffering form hand to mouth problem or
those people who are sustained from their daily income are defined as low
income individuals.

Thus, health insurance products have different types of health insurance plans which have
different and has unique set of needs.

5. What is health care management? Explain the problem of health care management
in Nepal.
Health care management refers to planning, organizing, directing and controlling
of the operations and services provided by health care organizations. It involves
overseeing the administrative and clinical aspects of healthcare as well as
ensuring that patients receive high quality care.
Health care management in Nepal faces number of challenges. They are as
follows:
 Lack of proper plans and policies: The lack of proper plans and policies in
health care management can result in inefficient resources use, inadequate
access to care, poor quality care, fragmented care and inadequate
monitoring and evaluation.
 Lack of infrastructure: Nepal’s health care management faces a shortage
of resources, including equipments, supplies and qualified health care
professionals. Many hospitals and clinic lacks the necessary resources to
provide high quality care to patients.
 Lack of coordination: lack of coordination can result in duplication of
efforts, fragmented care, inefficient resources and use and inadequate
monitoring and evaluation.
 Based on outdated technology: outdated technology can hinder the
effectiveness and efficiency of health care management in Nepal. To
address these issues, health care organizations need to invest in modern
technology and ensure that health care providers are trained to use these
tools effectively.
 Lack of skilled manpower: The health care sector in Nepal has a shortage
of skilled health care professionals, particularly doctors and nurses.
Retention of qualified staff is also a challenges as many health care
professionals migrate to other countries in search of better opportunities.
 Lack of supply chain and logistic management: These issues can have a
negative impact on patient care and the effectiveness of health care
services. It can lead to delays in service delivery with patients waiting
longer than necessary for medical care. Investing in technology and staff
training can help to streamline supply chain process and enhance
inventory management.
 Lack of awareness: lack of awareness is major challenges by health care
management. It can result in poor health literacy among patients.

Thus, these issues will require significant investment in health care to improve
the quality of health care services in Nepal.