Any scheme for public welfare and benefit carries no sense in case it does not operate on expected lines and when it is the question of health and related matters, reducing the financial burden on account of hospitalization and ensuring the beneficiaries received quality healthcare, Pradhan Mantri Jan Arogya Yojna (PMJAY) was introduced in 2018. We feel that a Healthcare scheme on such a large scale initially facing certain hiccups in the process of implementation is understandable but even after two to three years, there should pile up claims and settlements thereof appearing either to be not matching with the levels of expectations or keeping in view the long time factor taken to settle them, is totally unacceptable. Like this, in whichever part of the UT it is happening, it is bound to go against the spirit of the scheme and put a brake on the UT’s share of accelerating the progress towards achieving Universal Health Coverage and Sustainable Developmental Goals. In Kashmir division, in this connection, many private Hospitals, Nursing Homes, Dialysis Centres etc are sore on account of the fate of the relevant claims submitted by them to the concerned agencies running into crores of Rupees, continuing to remain uncertain. While new cases and fresh claims in many cases are being submitted, the pending ones, as reported, have either been returned or in proportions of peanuts settled. In other words, bills and claims worth Lakhs of Rupees are settled for a few thousands of Rupees only. The overall Healthcare, as such, is bound to take a hit, again to the peril of the deserving ones seeking to avail of the benefits of the scheme. There are, however, a few questions needing clarification as to whether the current scenario of unsatisfactory rather poor rate of claims settlement has remained the same throughout or pertaining to a certain period only in respect of the bulk of such claims. Again, whether and as claimed, that most of the claims have been rejected, in such cases have cogent and specific reasons been cited by the settling agency. Whether in time bound manner, such deficiencies in submitting claims have been rectified and claims re-submitted. Whether at the time of preferring claims, have all the required formalities, information and papers mandatorily required been submitted or not. There is a “check list” always to be referred and needed to be verified from, while filling the claim papers with the sole aim to avert delays and make the process of clearing claims smooth and fast. If all these factors have been duly taken care of while submitting claims and no formality is left or thought as optional, then the matter of nonsettlement of claims assumes sensitivity of a serious nature which must be expeditiously addressed. However, one main difference between any reimbursement made by the Government to the beneficiaries under whatever schemes etc, compared to PMJAY scheme where the claims are to be settled by the designated Insurance Companies as this Healthcare scheme is Government backed only. Further, it is to be noted that there are as many as 1350 medical packages covering surgery, medical and day care treatments, medicines and even transport as also covering secondary and tertiary care hospitalization which require proper scrutiny. Another most important thing about the scheme in the context of Jammu and Kashmir is that principally ”each and every family is eligible “to be covered under PMJAY up to an annual limit of Rs. 5 laks. It is, therefore, a natural corollary that on comparative basis, there must be more claims also which, though being no ground for justifying delays and deferments in settlement, warrant early settlement provided, again. that the papers are complete in all respects which at the time of submitting, need to be thoroughly scrutinized. It needs to be underlined that cashless and paperless access to quality healthcare services are available under the scheme.
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