Attempts being made to disrupt services under scheme: HS
‘Insurance company, not Govt, incurred losses’
Bivek Mathur
JAMMU, Oct 14: The Jammu and Kashmir Government today reacted to what they labelled as a “misinformation campaign” surrounding the implementation of the PMJAY-Sehat Scheme in the Union Territory.
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Addressing media persons here, Secretary Health and Medical Education Department, Bhupinder Kumar, accompanied by Divisional Commissioner, Jammu, Ramesh Kumar, said that certain unverified media reports have been generating a lot of doubts in the minds of people of Jammu and Kashmir, claiming the UT had suffered a loss to the tune of Rs 500 crores in the execution of the PMJAY-Scheme in Jammu and Kashmir.
He, however, said that the closer examination of the facts unveils a completely different story.
According to Kumar, the heart of the matter lies in the financial details of the PMJAY-Sehat Scheme. He said that total premium paid to Bajaj Alliance, the insurance company responsible for the scheme, during the entire policy period, which began on December 26, 2020, and continued until March 14, 2022, including an interim period of 79 days on a stop-loss basis, was Rs 304.59 crores.
“This number contradicts the allegations by certain digital and print media platforms that the scheme costs Rs 500 crores,” he clarified.
The Health Secretary said that during this one year and 79 days’ period, the insurance company paid out claims to the empanelled public and private hospitals, totalling Rs 398.41 crores.
“As a result, instead of turning a profit, the insurance company, and not the Government, incurred a significant financial loss of Rs 93.2 crores. These crucial facts are enough to counter the baseless claim of Rs 500 crores’ scheme,” Kumar said.
He said allegations have also been made regarding the termination clause of the contract between Bajaj Allianz and the State Health Agency, J&K.
Quoting media reports, he said, it has been alleged that the renewal of the contract period between Bajaj Allianz and SHA had to be reviewed after two years.
“It is crucial for us to clarify that the contract, which was awarded to Bajaj Allianz through competitive bidding, using Model Tender Document issued by the National Health Agency, had a fixed duration of three years, renewable after every 12 months,” he said.
The Health Secretary said that one of the conditions of the contract was that the continuation beyond the first year depended on mutual agreement between both parties.
“In this case”, he said, “the insurance company expressed unwillingness to continue the contract beyond the initial year due to incurred losses. Despite efforts to maintain the contract, the company decided to exit after a period of one year.”
To prevent service interruption, the Health Secretary said that the State Health Agency, J&K, entered into an agreement with Bajaj Allianz to continue services on stop-loss basis until a new insurance company was selected.
“Under this agreement, one of the conditions was that the insurance company didn’t share the risk of loss or claims, and the entire claims were to be borne by the J&K Government and the National Health Authority,” said Bhupinder Kumar.
He said, “the financial details underscore that the interim arrangement, with 15% administrative charges as per the express guidelines issued by the National Health Authority was the most cost-effective option serving the public interest during the transit period of 79 days.”
“Out of Rs 124.27crores released during this interim period of 79 days, only Rs 5.85 crores were paid as administrative expenses to the insurance company and the balance amount of nearly Rs 119 crores was disbursed as claim fund to the empanelled public and private hospitals,” he said.
He said the interim arrangement with the existing insurance company continued seamlessly benefitting over 69000 individuals.
He further said that this interim arrangement was thoroughly vetted by the Law Department, Finance Department, and the Advocate General, demonstrating that it was a well-considered decision against allegations of the unverified media reports that claimed that Government ignored the advice from its own departments.
Reacting to another allegation concerning the alleged increase in the number of eligible families covered under the scheme to over 10 lakh during the interim period of 79 days, the Health Secretary said: “this claim is unfounded and baseless.”
“The number of eligible families remained consistent at 21.24 lakh during the policy period from December 26, 2020, to December 25, 2021, and the 79-day interim period that followed.”
He added that the Government of Jammu and Kashmir has diligently followed the guidelines of the National Health Authority, Government of India, for the implementation of the scheme.
“Since the launch of the PMJAY-Sehat Scheme, the Government has paid a total premium of Rs 1175.32 crores to various insurance companies. In return, these insurance companies have disbursed a total of Rs 1249.33 crores as the claims to the empanelled hospitals,” he said.
The Health Secretary said that the insurance scheme has provided essential medical treatment to a significant number of patients.
He said over 5.6 lakh patients received treatment for various conditions, including 21557 cancer patients, with a cost of Rs 117 crores on their treatment, 20000 cardiac patients, with a cost of Rs 170 crores on their treatment, and nearly 10000 patients requiring dialysis, have also benefitted under the scheme.
“This insurance model has shifted the risk to insurance companies, which have paid nearly Rs 74 crores beyond the premium to the empanelled hospitals. This has rather strengthened the healthcare model within the UT of J&K and reduced out-of-pocket expenses, preventing catastrophic payments by poor families in need of hospitalisation,” said the Secretary Health and Medical Education Department.
He added that the scheme has not only provided medical support but also created employment opportunities in both public and private hospitals.
A patient satisfaction and feedback system has also been introduced under the scheme, with positive feedback received from nearly 99% of the patients who received treatment from the empanelled Government and private hospitals, he said.
“However, it is worth noting that there have been attempts to discredit this scheme through misinformation,” he further said.
“Such allegations are intended to disrupt the services provided to the patients in need and are totally baseless and meant to defame the Government and hence are vehemently denied,” he said.
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