Know about SEHAT Health Insurance Scheme

Dr. Daleep Pandita
Getting good quality healthcare at affordable cost is not only our fundamental expectation but the ultimate need of every citizen of this country. Lack of accessibility to technically sound hospitals equipped with competent expertise, at exorbitant charges finally increase the agony of patients many fold, which in turn cripple the development of our nation.
Government of India pre attempted this vital issue by covering its poor population particularly people living below poverty line, which are listed as per Socio – economic Caste Census of the year 2011 ( SECC – 2011 ) , through Ayushman Bharat – Pradhan Mantri Jan Arogya Joyna ( AB-PMJAY ). It is world’s largest health insurance scheme, which provide free of cost medical treatment to such families for Rs five lacs undertaken at Government and specifically designated hospitals all across the country.
Taking forward this concept, Modi Government on 26 December, 2020 obliged the people of Jammu and Kashmir by announcing the continuation of this free of cost scheme to its all residents. So the extension of this universal AB-PMJAY to entire population of J&K including its employees and pensioners, irrespective of economic status, be it unemployed or employed is popularly known as SEHAT Health Insurance Scheme.
This ambitious paperless and cashless scheme, implemented through ” e-card ” commonly known as Golden Card, issued through head of the family, covering its all family members, as mentioned in their ration card, for an amount of Rs. Five lacs on floater basis, for a period of one year extended to one or all the members of such family. Ration card for authenticating the resident of J&K and Aadhar card for identifying the beneficiary, are the two main documents required for taking this insurance cover besides domicile certificate and photograph as supporting evidences. It can be mainly availed at nearest Common Service Centre among the network of its 5000 centers spread all over J & K , besides Khidmat Centres, Community Health Centres, District Health Society, Associated Hospitals, Nodal offices of Relief and Rehabilitation department or through designated offices of State Health Agency, without paying any premium amount for taking this insurance policy.
No prior health examination or any type of prior medical tests are required to be undertaken by the eligible persons for getting enrolled in this scheme. So even all types of pre existing ailments or any kind of pre existing diseases are covered for their undertaking treatment under this scheme. It has no age bar and covers persons from infants to senior citizens and most importantly there is also no limit on the size of a family those can be covered under SEHAT scheme. This social benefit scheme also covers expenses up to three days of pre-hospitalisation like charges spent on diagnosis and 15 days of post-hospitalisation expenses incurred on treatment of a disease beyond the main period of its hospitalization like charges spent on medicines. Further, this scheme also takes care of expenses spent on room rent and bed charges, consultation fees, on laboratory tests and diagnostics etc.
Interestingly, the benefits under this scheme are portable for undertaking the treatment in any of the empanelled designated hospitals of AB-PMJAY all across the entire country, those can be easily located on various websites / portals. But expenses incurred on the treatment of a disease or ailment caused due to consumption of banned drugs or intoxication or as a result of any unlawful or criminal activity are not covered under this scheme. Similarly costs incurred on cosmetic or on ornamental treatment or on tonics not forming the part of actual treatment or any other medicines not prescribed, are also not payable.
This ambitious SEHAT health insurance scheme can prove a game-changer as far as healthcare in J&K is concerned but its effective and honest implementation at all levels in a system overweighed by corruption and capitalism is the main key to its success. Adequate monitoring and anti fraud mechanism from the Government side need to be placed in order, both at macro and micro level, to maintain check and balance on quality and cost of treatment, is also the need of hour. To resist the temptation to inflate insurance claims, irrational and over use of medical intervention besides unethical practices at the health institutions is the next step to be monitored by its implementers.
Free healthcare alone can not guarantee sound health of a society and its nation without the network of efficient healthcare mechanism at affordable cost, as finally the sincerity, true consciousness and morality of its people ultimately prevail upon for the success of any social benefit scheme.
(The author is former Regional Manager of Govt. of India PSU insurer and Ex Nodal Officer for J&K COVID-19 Health Insurance Scheme )