Dr. Daleep Pandita
Getting good quality medical care at affordable cost is our fundamental expectation. Recently launched world’s largest health insurance scheme namely Pradhan Mantri Jan Arogya Yojna ( PMJAY ) is a major step to address our this type of genuine expectation. But little has been done by the Government and the concerned authorities to create much needed awareness about this scheme. Removing its doubts and clarifying its ambiguity for the masses is the need of the hour.
Popularly projected by the Government as Modicare, this health care scheme covering more than 55 crore persons through about 11 crore beneficiaries as head of their families, cover forty percent of country’s poor and vulnerable population. So most of the economically weaker and lower middle class sections of our society can avail benefits of this health insurance scheme. In present times, it is the world’s biggest social security scheme. Families listed as per Socio Economic Caste Census of the year 2011 (SECC – 2011 ) are covered in this scheme.
This paperless scheme is implemented through ” e-card “, commonly referred as ” Golden card ” containing beneficiary’s details as per SECC – 2011 including its identification number and Q R code, that is easily accessible on pan India basis. This card is readily available at Common Service Centre, Khidmat Centre, Community Health Centre, District Health Society or at designated offices of State Health Agency, against nominal charges of Rs. 15 per card. Due to national portability of this scheme, it remains valid all over India. So a resident of one state can avail this facility in any other state also. Conceptually, it is “Entitlement based and Enrollment based ” free health insurance scheme. It is funded through cost sharing basis between the centre and the states in the ratio of 60 : 40 and more than 30 States and Union Territories having already signed Memorandum of Understanding to this effect. The entitled enrolled beneficiary has not to bear any cost or to pay any insurance premium for availing benefits under this scheme.
No prior health examination or any type of tests are required to be undertaken by the eligible persons for their enrollment in this scheme. From infants to senior citizens, there is no bar on the age and most importantly on the size of the family, for entry in to this scheme. Further any pre existing disease, meaning person who is already having any disease or ailment prior to the entry of this scheme, is also covered under it.
This scheme provides cashless insurance cover to the maximum of Rs. Five lac, that floats to all the members of a family for one complete year. It covers the expenses incurred on the hospitalization of 1350 identified medical conditions, for their secondary and tertiary healthcare treatment. It also provides cashless treatment for 3 days of pre hospitalization and 15 days post hospitalization period spent on the treatment and or recovery of the disease or ailment. It also takes care of room and bed charges, consultation fees, charges of laboratory tests and diagnostics etc.
Cashless treatment under this scheme can be undertaken at all Government hospitals including all Medical College Associated Hospitals and there are more than 16,000 designated hospitals, all across the country those are empanelled for implementation of this scheme. Equal number of private health care centres are also in the pipeline for their empanelment, out of which about 8000 have been already empanelled under this scheme. Update on the list of empanelled hospitals and their services is available on www.pmjay.gov.in.
Expenses incurred on the treatment of disease or ailment caused due to banned drugs, intoxication or as a result of any unlawful or criminal activity are not covered under this scheme. Similarly costs incurred on cosmetics or ornamental treatments or on tonics not forming part of treatment, or on medicines not prescribed, are not payable under this scheme. Government has provided toll free helpline numbers at 1800 233 5554 or 1800 111 565 for the effective and successful implementation of this social security scheme.
Free medical insurance alone can’t guarantee sound health to all without a network of efficient healthcare mechanism at affordable cost. Adequate monitoring from government side needs to be placed in order to maintain check and balance on quality and cost of treatment. To resist the temptation to inflate insurance claims, anti fraud mechanisms need to be strengthen to deter health care institutions from cheating. The moral hazard problem, irrational and over use of medical interventions, unethical practices etc. also need to be taken care of. Strong political will is required for an affordable healthcare system, which is not possible in a system that is overweighed by corruption and capitalism.
(The author is Senior Divisional Manager with Govt. of India P S U Insurer at Jammu)
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