Majority of the complaints pertain to settlement of claims

Within eight months of the launch of the Pradhan Mantri Jan Arogya Yojana (PMJAY), 213 complaints have been filed, with the maximum grievances – of 59 – being against insurance companies. A majority of these complaints are related to settlement of claims.
Apart from insurance companies, 42 complaints have been filed against hospitals, a majority of which pertain to malpractices and fraud.
Under PMJAY, also referred to as Ayushman Bharat or Modicare, the government aims to provide a health insurance cover of Rs 5 lakh to 500 million Indians free of cost. This includes families from lower income groups that fall under the socio-economic caste census (SECC) data of 2011. This scheme was launched in September last year.
“We are being blamed for poor implementation of care in hospitals. How can an insurer be held responsible for the medical facilities,” said a senior public sector insurance official. Interestingly, the majority of complaints filed against insurers are by hospitals.
Insurance sector insiders, however, claim that malpractices are originating from the hospitals and there is no regulator to keep a check on these practices. As of April 3, a total of 1.8 million beneficiaries have sought medical facilities under this scheme.
Data from the General Insurance Council showed that the insurers collected Rs 5842.56 crore as premium under various Central and state government health insurance schemes in FY19. This was an 85.38 percent growth over the previous year.
The cash-less scheme will cover medical and hospitalisation expenses for almost all secondary and most tertiary care procedures. PMJAY has defined 1,350 medical packages covering surgery, medical and day care treatments including medicines, diagnostics and transport.
While the scheme has an insurance route as well as trust route, a majority of states have opted for the latter. The trust model involves the state setting up a dedicated trust for deployment of funds towards payment of insurance claims.
Insurance companies, on the other hand, are part of the tender process where those bidding the lowest are selected to implement the scheme in the particular state.

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