Over 30,000 families living below the poverty line in Asia's largest slum at Dharavi may soon have insurance cover for their medical expenses and regular health check-ups, thanks to a unique care model.
The scheme focuses on partnership between general physicians and the poor families through a health maintenance organisation, supported by a general insurance company and micro-financing institutions.
A year's research by actuaries has gone into the making of this model, being developed by RD Lele, an eminent physician of Mumbai. The pilot project is likely to start soon. The premium for health cover and the contours of the policy will be designed on the basis of data collected from the pilot project.
A survey carried out by actuaries in the Dharavi slums revealed that, on an average, a family below the poverty line spends Rs 75 to 300 per medical transaction and Rs 5,000 annually on healthcare.
General physicians usually overcharge the poor and prescribe unnecessary diagnostic tests for even minor ailments. By forming a co-operative scheme with physicians, the primary care cost will be brought down considerably under the scheme.
The idea is to collect Rs 5,000 annually from each family as subscription to the HMO. This will create an annual corpus of Rs 5 crore (Rs 50 million). Using this money, each member of a family can get a fixed number of free medical check-ups.
Besides, the breadwinner of the family can get a life insurance cover, while other healthy eligible members can get a health insurance and personal accident cover.
Those who are not eligible for health insurance can get a cover for periodic consultations with specialists, necessary investigations and hospitalisation, if required, besides getting drugs at a discount.
Unlike the conventional indemnity health insurance cover, which excludes a few ailments, there is to be no exclusion in the HMO coverage, which will also cater to HIV+ patients, mental patients and patients with chronic diseases.
The proposed HMO, a not-for-profit organisation, is being supported by Prestige Healthcare, a healthcare company.
Said Girish Rao, managing director, Prestige Healthcare, "We have the competence to provide the support and network with hospitals and physicians. The facts and figures from the study justify the need for such an HMO. The key challenge is to develop the right model which can have a viable claims ratio and is sustainable for all stakeholders over a long term."
Once the model is developed and the premium for the cover fixed, talks will be held with microfinance institutions and life and general insurance companies to support the HMO through group insurance. Micro-finance agencies will provide loans to the families to pay for a year's cover.
Said Lele, the brain behind the model, "The importance of the HMO approach with emphasis on prevention for the entire Indian community can be appreciated from the fact that by 2025 half the world's cases of diabetes mellitus will be in India. Mumbai will have its own share."
One of the largest cooperatives in Singapore, NTUC INCOME, had evinced interest to be part of the HMO and was involved till the research stage, but backed out as the model was not for profit.
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