The BJP government in Rajasthan is scrambling to salvage its flagship medical insurance scheme, the Bhamashah Swasthya Bima Yojana, after the lone company involved in the project threatened to pull out citing non-payment of a part of the premium by the health department. Official documents assessed by Outlook show the fractious relationship between the New India Assurance Company (NIAC) and the government over the scheme—launched in 2015 to provide cashless medical insurance cover to families living below the poverty line.
Rajasthan chief minister Vasundhara Raje’s project is believed to have provided the framework for Prime Minster Narendra Modi’s national health protection scheme, Ayushman Bharat. Rajasthan goes to the polls on December 7 and the opposition Congress has red-flagged the state scheme to pin down Raje, already facing massive anti-incumbency and allegations of running an autocratic government.
The company and the Rajasthan State Health Assurance Agency (RSHAA), a body under the health department which is implementing the scheme, are understood to have patched up after the NIAC sent a stinker over pending dues of over Rs 100 crore. For its part, the government is trying to plug the loopholes that have plagued the scheme. Outlook had reported in its June 11, 2018 issue (Scalpels in Air And Other Long Stays) that private hospitals had been using myriad ways for milking the scheme. Several hospitals were found to have either booked higher-expense packages for patients or insurance was claimed in cases where procedures were not even performed. “The government is ready to pay the premiums now. We are trying to stop the frauds… we are working together now,” says an NIAC official, pleading anonymity. Outlook reached out to Naveen Jain, the CEO of RSHAA, but he had not responded till the time of going to press.
In June, the NIAC had identified 66 hospitals that allegedly made fraudulent claims, and de-empanelled them. The government, however, overturned the decision, with RSHAA saying the company did not have the mandate to delist hospitals. The NIAC retorted by pointing out to a clause in its agreement with the government which says that the “…the insurer may initiate the process of de-empanelment irrespective of penalty clause for the hospitals”.
The lack of transparency between the two was one of the issues raised by the NIAC in letters to Naveen Jain, pointing out “repeated short payments of quarterly premium, non-sharing of digital beneficiary data, non-implementation of biometric identifications of beneficiary claimants, non-implementation of live capturing of beneficiary photographs at time of admission/discharge etc”. The company says photographic evidence of patients is essential for detecting fraud.
False claims were one of the reasons why claims and premium are rising every year, NIAC sources say. For 2015-16, claims were at about Rs 320 crore, Rs 545 crore in 2017. As of September 12, claims for 2018 are already at Rs 610 crore, surpassing the previous year’s figure already. What compounded matters was the government holding back payment of Rs 106.74 crore beyond the 14-day deadline, which the company described as “arbitrary, unlawful and breach” of the Insurance Act. In an e-mail, the NIAC said “such deliberate short payment of due premium is in contravention of agreed terms and in clear violation” of the agreement. The company also called for discontinuation of the policy with “immediate effect and no future claims shall be admissible”.
Though the two have made up, sources said relations were far from smooth as fraudulent claims continue to pop up. The Congress says the very foundation of the scheme is faulty and likened it to a mining scam which had rocked the Raje government earlier. “Some of the conditions of the scheme are impossible (to fulfill) for a patient from a rural background. There are inconsistencies and loopholes in the scheme itself… There is a lot of corruption in this scheme,” says Archana Sharma, spokesperson and vice president of the Congress’s Rajasthan unit.
Rising Claims In Rajasthan
The New India Assurance Company says its payouts aregoing up each year
- Rs 320 cr (December 2015 to December 2016)
- Rs 545 cr (January 2017 to December 2017)
- Rs 633 cr (January 2018 to September 2018)