Pradhan Mantri Jan Arogya Yojana (Pm-Jay)

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The Pradhan Mantri Jan Arogya Yojana is the world’s largest health insurance scheme launched by the Government, under the recommendations of the National Health Policy, 2017. It was launched to achieve the goal of universal health coverage. This scheme was previously known as the National Health Protection Scheme.

Since its inception on 23rd September, 2018, the PM-JAY has treated fifty lakh people within a year, investing upto Eight Thousand Crores for secondary and tertiary treatments. Recently, about 171 hospitals were de-listed from the PM-JAY Scheme for alleged frauds and FIRs have been lodged against them.

Salient features of the Pm-Jay scheme

After its incorporation on 23rd September, 2018 under the guidance of Honourable Prime Minister Shri. Narendra Modi, the basic aim of the PM-JAY was to cater the medical insure needs of the poor and vulnerable families across India. The insurance was to be completely sponsored by the Government.

This sponsorship is shared between the Centre and the State Governments as per the guidelines of the Ministry of Finance. The scheme aims to bridge the gap between availability of hospitals to the poor and seeks to reduce the expenditure on hospitals.

The scheme will provide cover of Rs. 5 Lakh per family (can be used by one or all members of the family) per annum for families listed under the Socio -Economic Caste Census of 2011, from both rural and urban areas. One of the most important features of this scheme is that it doesn’t discriminate between the size of the poor families. Almost 11 crore families and 50 Crore beneficiaries have been enrolled under the PM-JAY.

Critical analysis

The Pradhan Mantri Jan Arogya Yojana supersedes the earlier prevailing Rashtriya Swasthya Bhima Yojana, 2008. The scheme also includes the list of families enrolled in the RSBY, 2008. It has taken a huge leap over the past two years and has provided advancements in the field of health insurance for poverty laden families. Since 2018, it has empanelled many hospitals under its network.

More than 20 thousand hospitals have been empanelled under the wing of the wing of Pradhan Mantri Jan Arogya Yojana. The health standards have improved immensely in the past year, lowering the death and infant mortality rate in the vulnerable families. It is also to be noted that public hospitals are reimbursed for the healthcare services at par with the private hospitals under this scheme, reducing the enormous amounts of money charged by the private hospitals.

This will be a good step forward as, since the early 1990s the governments gave way for the establishment of private hospitals which lead to huge feels and over diagnosis. However, the scheme is not entirely efficient as it is vulnerable to frauds. There is no hard and fast rule as to how the government ensures that the bills are not flawed and that the people are not exploited under the scheme.

The only way to ensure that the fraudulent activities have not taken place is to ensure electronic billing and the vigilance of the government’s IT Department. However, not all the hospitals in the remote areas are yet acquainted with digital billing, thus increasing the possibilities of commission of a fraud.

Performance so far:

So far, the Pradhan Mantri Jan Arogya Yojana Incentive Scheme has performed fairly well. However, there have been doubts and several questions have been raised over the efficiency of the scheme. It has acted as a link for public money going into private hands. Under this scheme, different insurers are enlisted for different cities and states, making life difficult for people who are being treated outside their hometown or state.

The chances of fraud commission are huge due the inefficiency of the scheme. The scheme only improves the financial stability of the vulnerable families; however, the quality of treatment and care should be of utmost importance and has been completely neglected by the scheme. The scheme will be of no use if there are no advancements in the medical technology. Primitive measures of treatment make this scheme a complete failure. 

Recent frauds:

The National Health Authority of India (NHA) under due deliberations with its anti-offence wing National Anti-Fraud Unit (NAFU) has de-listed 171 hospitals for alleged fraudulent activities. After the due diligence carried out by the Anti-Fraud Unit, it was found out that there were some entries of ‘suspect’ electronic-cards in the databases of the hospitals.

It was also found out that certain insurance schemes for which only government hospitals were authorized were being used by the private hospitals under the guise of ‘Unspecified Package’. It has been detected that most of the hospitals operating on fraudulent activities are from Maharashtra.

A fine of Rs. 4.5  crores has been imposed on such hospitals, along with First Information Reports which have been filed against the hospitals in Maharashtra, Uttar Pradesh, Uttarakhand and Jharkhand. To curb this issue, the government has come up with mandatory biometric authorization of the electronic cards of the beneficiaries at the time of their admission and discharge.

Conclusion

The Pradhan Mantri Jan Arogya Yojana is indeed a great initiative for medical insurance for poor and vulnerable families. However, lack of planning and incompetency of the government’s IT department has made this scheme prone to misuse. Moreover, the scheme aims at providing insurance facilities and not at improving the quality of treatment.

Several hospitals across India have improper health hygiene leading to several unwarranted deaths of their patients. The scheme aims at reducing catastrophic and out of pocket health expenditure and will slowly move towards the Universal Health Coverage as cited by the World Health Organization. India is still far from reaching the overall health goal.

This desire will be halted by many problems but one should be optimistic about this goal in the longer run. The intention where primitive health coverage is not a privilege to some but all the people will be created in the longer run and people will have the Pradhan Mantri Jan Arogya Yojana to thank for.

Author: Amogh Taskar from DY Patil College of Law, Navi Mumbai.

Editor: Tressa Maria Joseph from Symbiosis Law School, Hyderabad.

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