Rajiv Gandhi Jeevandayee Arogya Yojana – How the hospitals and insurance company may profit
Jeevandayee scheme offered by Maharashtra Government provides health insurance cover up to Rs1.5 lakh for families earning less than Rs1 lakh per year. Will the genuine customers be given treatment and false claims denied? Find out the progress and hurdles
The State Government of Maharashtra has launched Rajiv Gandhi Jeevandayee Arogya Yojana (RGJAY) in order to improve medical access facility for both Below Poverty Line (BPL - Yellow card holders) and Above Poverty Line (APL- orange card holders) families. RGJAY is already implemented in eight districts including Mumbai and would be implemented throughout the state of Maharashtra in phased manner for a period of three years.
Find out more about the scheme - http://moneylife.in/article/rajiv-gandhi-jeevandayee-arogya-yojana-what-you-need-to-know/30348.html
As with any other well-meaning government health insurance scheme, RGJAY has been having problems in implementation. There have been reports of some private hospitals profiting from unnecessary surgical procedures and high-cost procedures instead of treating the patient by medicines.
Clearly, the hospital business depends on number of procedures done. The State Government has purchased the insurance cover from National Insurance Company (NIC), who pays the hospitals for any procedures that are performed. There are limited numbers of good private hospitals on the panel of RGJAY and hence it may be difficult from RGJAY society to taken stern action against errant hospitals.
According to Dr Raju Jotkar, assistant director, RGJAY, “Given the infancy of RGJAY since inception on 2 July 2012, it would be too early to pass on any such judgements without any tangible evidence. However each network hospital is under scanner of RGJAY.”
RGJAY has implemented processes to ensure that the cracks in the system for pilfering are covered. Dr Raju Jotkar, says, “The network hospital is likely to opt for high-end package over low-end wherever feasible. However, the built-in preauthorization review for each request by network hospital by insurer as well as RGJAY society (Government) offers an opportunity to control such demands if any in light of evidence. The two layered scrutiny removes all biases as well as detect the unreasonable requests precisely. Moreover, RGJAY have reserved 132 procedures having risk of abuse to public network hospitals only. Over and above this oversight and vigilance mechanism helps to capture any misbehaviour or irrational requests of network hospitals.”
RGJAY society has paid NIC premium of Rs333 per family (service tax extra) for about 49.2 lakh beneficiaries, of which two quarterly premiums have been paid till date. It means they have paid the insurance company premium of Rs82 crore for two quarters ending December 2012. There has been media report a month ago of the insurance company already having paid Rs60 crore in claims and that they have refused to extend its services beyond the present eight districts as it is dubbed as a loss-making proposition. Dr Jotkar is tight lipped about it with the response “It would be prudent to pose this question to NIC.”
While the steps taken by RGJAY society will help ensure that false claims are denied, how will it ensure that genuine customers are given treatment? The first level of authorisation for the procedure is from insurer or rather TPA (third party administrator). With heavy incurred claims within two quarters of the scheme launch, will the insurance company (or TPA) keep its profit margin by refusing approval for the procedure? Even though it cannot be asserted at this time, it is all too familiar with other Government schemes like Rashtriya Bima Swasthya Yojana (RBSY) in Maharashtra.
Maharashtra Government had sought a probe by the Central Bureau of Investigation (CBI) into non-settlement of claims by insurance companies under RBSY, Labour Minister Hassan Mushrif told the Legislative Council. The labour minister conceded that the RBSY scheme was tailor-made for insurance companies to earn profit. In Maharashtra alone, Rs215 crore were paid as premium and claims of Rs134 crore were not settled by the insurance company.
In the third part of the series we will cover details of insurance company and TPA payment for RGJAY insurance cover. Gaurang Damani, well-known activist, had filed an RTI query to find about the TPA incentive to reduce claims ratio.
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