Ayushman Bharat v/s Mediclaim Insurance

By our Special Correspondent

The State Administrative Council or SAC in its 20th meeting held on August 11 under the chairmanship of the then Governor,  N N Vohra approved roll-out of Ayushman Bharat-Pradhan Mantri Rashtriya Swasthya Suraksha Mission or PMRSSM in the State.
The flagship scheme, as given out in the press statement, is avowedly aimed at providing assured health coverage of up to Rs 5.0 lakh per family per year for secondary and tertiary care hospitalization covering1350 identified diseases through a cashless procedure with the help of a smart health card bearing an unique ID. 
The healthcare services will be delivered through a network of public and private healthcare providers. According to the information available with this newspaper, a total of 6,13,648 families comprising 36 lakh souls, which is about 29% population of the total population, would be covered under the Scheme.  As per the scheme a State Health Agency has been constituted with a Governing Council under the Chairmanship of the Chief Secretary. Similarly, an Executive Committee has been constituted for proper implementation of the Mission under the chairmanship of a Chief Executive Officer, who would be assisted by various health experts from the field of health insurance. The key feature of the scheme is that all Government Hospitals would be automatically empanelled and private hospitals would have to get empanelled to act as healthcare providers. Every Private and Public Hospital will have “Ayushman Mitra” who will act as a facilitator for admission and processing the claims of beneficiaries of the Mission.
The salient features of PMRSSM include, cashless and paperless scheme which provides access to services in any public and private empanelled hospitals across India with no cap on Family Size so as to ensure all members of designated families, specifically girl child and senior citizens, get coverage. The main feature of the scheme is its portability which means beneficiary can avail treatment in any empanelled chain of hospitals, both public and private, in the country; for all beneficiaries, a health card with a unique ID will be provided. The scheme is aimed to cut down pocket expenses of the beneficiaries and divert the savings to other activities like improving the nutritional status of the family. The contract for the underwriting insurance has reportedly been bagged by a private insurance company at a premium of Rs750 per family.

In stark contrast there to the SAC, in its meeting held on August 31st  under the chairmanship of the new Governor, Satya Pal Malik accorded sanction to the implementation of the Group Mediclaim Insurance Policy for all State Government Employees including Employees of PSUs/Autonomous Bodies/Universities on mandatory basis; and, Pensioners, AIS Officers, Ad hoc, Contractual, DRWs, Work charged/Contingent paid workers and their dependant family members on optional basis w.e.f. 1st October, 2018, for a period of one year and extendable annually for three years, based on claim settlement ratio and satisfactory performance of the Insurer.
As per the scheme the policy will include medical insurance cover of Rs 6 lakhs (as against Rs 5 lakhs under PMRSSM)  for individual employees up to 5 family members(No cap in PMRSSM as far as number of family members is concerned) with a Corporate Buffer of Rs 10 crore, the cost whereof is loaded in the quoted premium( No such buffer is provided in PMRSSM). The Rs10 Crore buffer is claimed to benefit a large number of employees and pensioners meant  to cover the expenditures incurred by them on identified illnesses over and above the expenditure coverage provided in the Policy.

The premium to be paid by the employees annually would be Rs 8776.84 minus Rs 3600 (Medical allowances currently admissible annually) equal to Rs 5176.84 as against Rs750/family under PMRSSM). To the shock and surprise of poor pensioners whose monthly income is slashed by more than half of their wages while in active service, the premium would be Rs 22,228 minus Rs 3600 (Medical allowances currently admissible annually) equal to Rs18,628, annually that is almost three times than that of the in-service employees. The annual premium will be payable in four installments to be deducted from the salaries in the case of the employees. Contrary to it, the premium in case of retired employees understandably has to be paid in one installment. According to informed sources Reliance General Insurance had offered  premium rate of Rs1900 for underwriting the health insurance under PMRSSM and stood at L3. This has raised many an eyebrow as the same company is offering more or less the same type of insurance to the employees at an all time high premium rates.

Further the terms of the policy are not clear about the inclusion or exclusion of local private and public hospitals  in the list of hospitals instead almost 5000 hospitals across the country have been identified and approved for purposes of the scheme. A significant step up over the previous policy in that it covers domiciliary hospitalization and day care procedures also. The new policy is however viewed as women employee-friendly as the expense cap on maternity cover has been enhanced to Rs 30,000 within State and Rs 70,000 outside the State. A concession to the  pensioners is that they would not be required to undergo pre-policy tests and all their pre-existing diseases would receive immediate coverage.  There is also a new provision for the insurance coverage of the dependent family member’s up to 100 years as compared to 80 years in the previous policy.
It is claimed that the insurer will provide a Management Information System (MIS) report regarding enrolment, admission, preauthorization, claim settlement and other information about the services as required by the government on a regular basis.
Further, the website designed by the insurer will have district-wise/state-wise enrolment status, claims, treatments rendered and hospitals data. Stage wise tracking facility for claims and grievances shall also be available to the beneficiaries, this is certainly an improvement over the previous years’ Mediclaim policies.
Besides,  services of a professional consultant have been hired to set up a robust grievance redressal system for employees and pensioners. The consultant has already set up grievance redressal offices in all districts and these offices can be accessed by the employees and pensioners in case they have any grievance regarding implementation of the policy, claimed the officials.

However, the government  continues to maintain a silence over the allegations of extending undue benefits to a particular insurance company, which is unfair and not caring even two hoots for the voices of dissent from elected representatives and employees leaders. Despite repeated attempts the Principal Secretary Finance, Navin Kumar Choudhary could not be contacted