Health claims

Published : Aug 28, 2009 00:00 IST

in Chennai

THIS government considers providing compassionate medical service to humanity as service to God. Accordingly, after this government assumed charge in 2006, a number of measures have been taken towards the medical needs of the poor. This is the declaration made by the Dravida Munnetra Kazhagam-led government in its policy note on Health and Family Welfare for 2009-2010.

On July 23, close on the heels of the debate on the performance of the government in the health sector in the budget session of the State Assembly, the government launched a new health insurance scheme, called Chief Minister Kalaignars Insurance Scheme for Life Saving Treatments. The scheme, which is being implemented through Star Health and Allied Insurance, a private insurance company, will enable over one crore poor and downtrodden families to receive specialist treatment costing up to Rs.1 lakh for 51 types of diseases. The government has released the list of diseases, treatment and surgical procedures covered by the scheme. Treatment for diseases under 13 disciplines, such as cardiology, oncology, nephrology and urology, neurology, orthopaedics, ophthalmology, gastroenterology, plastic surgery, gynaecology, thoracic medicine and haematology comes under the purview of the scheme. The list also includes thyroid surgery; major surgical procedures requiring inpatient care owing to accidents and other kinds of trauma; management of coma; meningitis and encephalitis; and surgical corrections of congenital deformities.

All the members of the 25 welfare boards and their family members, including dependent parents, and any family whose annual income is less than Rs.72,000 are eligible. The boards include those formed for farmhands, construction workers, manual labourers, autorickshaw and taxi drivers, tannery workers, scavengers, transgenders, tribal people, fishermen, domestic workers and folk artists.

The government is already running a health insurance programme for the employees of government departments, local bodies, public sector undertakings, statutory boards and government universities through the same private company.

Administrative sanction to implement the new scheme at a cost of Rs.517.307 crore a year as premium for four years, including service tax to the tune of Rs.48.307 crore, has been issued. The government has promised to provide additional funds in the Supplementary Estimates for 2009-2010.

The State Empowered Committee constituted under the chairmanship of the Chief Secretary to review the implementation of the scheme approved on June 8 Rs.469 as the premium per family, inclusive of the card cost but excluding the annual service tax, official sources said, adding that the L1 tenderer had originally quoted Rs.999 as premium. The committee accepted the terms of the additional undertaking given by the company that in case the claim ratio worked out to less than 65 per cent of the premium paid during the policy period, the difference between the incurred claim at the end of each policy period and 65 per cent of the premium, inclusive of the card cost, would be paid back to the government.

Chief Minister M. Karunanidhi, who presided over the function to mark the inauguration of the scheme, appealed to the Centre to waive the service tax on health insurance. He expressed the hope that the scheme would be replicated in other parts of the country. Although the scheme was launched with fanfare, almost all major Opposition parties have chosen to adopt a wait and watch strategy. This is because any criticism of the scheme, which is meant to benefit around 70 per cent of the States population, at this stage can become counterproductive.

However, the governments decision to implement the scheme through a private insurance company has thrown up several questions. Is the scheme viable? Does it not amount to the government shirking its social obligation of meeting the health needs of the poor? Will there be a level-playing field for hospitals in the government and private sectors under the scheme? Considering the cost of treatment offered in corporate hospitals, can the scheme really help the poor to get free treatment for serious ailments?

J. Gurumurthy, secretary of the standing committee (General Insurance), All India Insurance Employees Association, said such schemes would not be viable in the long run. Although pre-existing diseases were covered under the scheme, the sum insured per family was only Rs.1 lakh, he pointed out. On the governments assertion that more than one crore families would be covered, he said the figure itself was not credible. The amount was not sufficient for specialist treatment, particularly in corporate hospitals, he opined.

He said no insurance company with a profit motive would provide medical insurance free of cost. If there was a break-even level, the companies would be able to offer 70 per cent on claims, keeping the remaining 30 per cent for administrative expenses. If they wanted to make a profit, the ratio should be below 70 per cent.

Instead of giving away 30 to 40 per cent of the premium to the insurance company, the government could have put the entire amount of Rs.2,068 crore into a corpus, which would have fetched Rs.200 crore a year by way of interest, he said. It could have used this amount for the treatment of as many as 20,000 persons. The government should think in terms of providing more funds to strengthen the 10,000-odd government hospitals, besides networking the hospitals run by the State and Central governments and welfare organisations, he added.

Major hospitals in the private sector should be asked to fulfil their corporate social responsibility by earmarking a part of their profit for free medical treatment of the poor, he said. A lot of complaints with regard to medical claims were pending before the insurance ombudsman as there was no law in the country to regulate hospitals with particular reference to doctors fee and hospital charges, he recalled. On the Insurance Regulatory and Development Authoritys (IRDA) claim that there was no single agency to monitor the claim settlement and no proper records were maintained for the health insurance schemes implemented by different State governments, he said if the agency was interested in regulating health insurance, as a first step it should ask the Central government to standardise and regulate medical institutions.

Dr C.S. Rex Sargunam, president of the Tamil Nadu Health Development Association, felt that upgrading government hospitals would go a long way in providing life-saving treatment to the needy. Now that the insurance scheme has been introduced, steps should be taken to ensure a level-playing field for government and private sector hospitals. The government should declare that such treatment and surgery would be available at the special wards of government hospitals too, he said, adding that the choice of treatment should be left to the patients.

The revenue generated from the insurance claims could be utilised for improving facilities in government hospitals, he suggested. Except for a few major surgical procedures, many of the diseases listed by the government for insurance cover could be treated at government hospitals, he said. Apart from enhancing the infrastructure and upgrading the medical equipment, efforts should be made to improve hygiene and sanitation at government hospitals, he said.

The All India Trade Union Congress (AITUC) and the Centre of Indian Trade Unions (CITU) are of the view that the government should have opted for a public sector insurance company for the implementation of the scheme with a view to ensuring its viability.

A. Soundararajan, general secretary of the State unit of the CITU, said the risk factor was high in implementing a scheme of such magnitude through a private company. Referring to the inadequacy of the scheme, he said, if the government adopted a something is better than nothing attitude, it would not serve the purpose.

Too much reliance on the private sector would demoralise the medical and paramedical professionals of government hospitals, he said. This would also result in the governments creeping withdrawal from its social obligations. The very purpose of a welfare state would be diluted. The government should strengthen the medical institutions in the public sector instead of neglecting them, he said. The CITU plans to launch a campaign for a viable health insurance scheme for workers implemented through a public sector insurance company.

S.S. Thiagarajan, general secretary of the State unit of the AITUC, said the sum insured was inadequate for medical treatment. He suggested that the insurance companies bear the cost of all types of surgery. He asked the government to increase the income ceiling for eligibility so that more people in the unorganised sector could benefit from the scheme.

Dr G.R. Ravindranath, general secretary of the State unit of the Indian Doctors for Peace and Development, said the new scheme would not help the poor people. Implementation of the scheme was not an isolated step; it was part of similar measures undertaken by the Central government and various State governments to privatise the tertiary medical care, he added.

Ever since the World Trade Organisation agreed to bring the service sector under its purview in 1993 and rules for the same were framed in 2000, the process of privatisation of the health sector was set in motion, he recalled. The National Health Policy, 2002, paved the way for privatising the primary, secondary and tertiary levels of medical care, besides corporatising the health sector in the name of promoting public-private partnership. This was done despite the fact that 80 per cent of the outpatient service, 60 per cent of the inpatient service and 80 per cent of the intensive care services were provided by smaller hospitals, he said.

Under the new scheme, the service provider would identify and enrol hospitals that would be networked. There should be a minimum of six hospitals in each district and 15 hospitals in major cities for networking as treatment would be available only in such networked hospitals, he pointed out. This move, he said, would result in irregularities.

The governments move went against the spirit of the National Health Bill, 2009, which had not yet been passed in Parliament, Ravindranath argued. He called for urgent steps to appoint adequate numbers of medical and paramedical staff in government hospitals and ensure that the functioning time of operation theatres was enhanced to 20 hours from the present eight hours on working days. With the total insurance premium remitted by the government for four years, 21 new medical colleges could be started and four super-speciality hospitals could be set up, he claimed.

V.K. Subburaj, Principal Secretary to the Tamil Nadu government (Health and Family Welfare), clarified that the new scheme was introduced as needy people sought assistance under the Prime Ministers Relief Fund and the Chief Ministers Relief Fund for life-saving treatment despite the availability of a huge network of health facilities in the government sector.

On the governments strategy to enrol the beneficiaries, he said an intensive campaign would go on until the first week of November. Around 750 teams had been formed to conduct camps at the district level and issue biometric cards to the beneficiaries. Meanwhile, members of the welfare boards can use the identity cards issued by the boards, and other eligible persons can produce the income certificate given by the village administrative officer for availing themselves of the health benefits under the scheme. Although the government intended to complete the enrolment process in three months, it could be extended for another three months if necessary, he added.

Over 300 hospitals had been networked under the scheme, Subburaj said. Implementation of the scheme did not mean that government hospitals would be neglected. In the past two years, the government has allotted Rs.500 crore to improve facilities at these hospitals, but this was not adequate to strengthen all hospitals in the government sector. It is a continuous process, he said.

Although the medical and paramedical personnel attached to government hospitals were in no way inferior to their counterparts in the private sector, only a few high-end surgical procedures were performed at government hospitals owing to non-availability of specialists, he said. The government was working out an incentive scheme for personnel of government hospitals. Treatment under the scheme would be provided in all the wards, including pay wards, he added.

On the claim that the insured amount of Rs.1 lakh was not sufficient for certain surgical procedures, he said the insurance company had worked out a package with the hospitals concerned and it had agreed to provide up to Rs.2 lakh for certain kinds of treatment. Responding to criticism on choosing a private insurance company for the task, Subburaj said the tender process was transparent. Ten companies had participated and the lowest tender was chosen, he pointed out.

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