Ayushman scheme: Punjab Government officials connived with insurance firm, finds inquiry

Vishav Bharti

Chandigarh, September 7

A government probe has found that to favour the ‘financially bleeding’ insurance company, the State Health Agency (SHA) terminated the contract midway and left 45 lakh families enrolled under the Ayushman Bharat Mukh Mantri Sarbat Sehat Bima Yojana to fend for themselves.

The probe was carried out after Chief Secretary Vijay Kumar Janjua sought report from the Health Secretary. The SHA was established by the government to the run scheme, which is always headed by a senior IAS officer.

Sources revealed the report had raised serious questions on the way government-run SHA and the department terminated the contract purely based on the opinion of a private lawyer instead of taking legal advice from the Advocate General. The report candidly noted that the legal opinion had ‘deliberate lapses’ to favour the SBI General Insurance Company, which was bleeding financially. The report has not ruled out the connivance of the SHA officials with the insurance company.

Apart from that the report noted the contract was not only terminated in a hurry without following the due process, but it also made the government’s case legally weak by issuing the termination order sans issuing a preliminary termination notice of 30 days.

The report further noted that after the date of termination, there was hardly any liability of the insurance company. The probe found that by not following the due process of termination, the government would be at a very weak footing while legally battling for recovering the penalties from the insurance company. “It clearly comes out that in the whole process, the insurance company seems to be the biggest gainer and the government, the biggest loser,” the report adds.

The probe has also raised questions on why the Finance Department was never consulted before making such a huge fiscal decision. “The Health Department or the SHA did not have any tie-up for funds from the Finance Department for running it in on Trust mode, neither did they have any ability to run it on that mode, then wasn’t it inappropriate to leave 45 lakh families to fend for themselves?”

The report also raised question over the Third Party Administrators (TPAs), who were mainly responsible for delaying the claim settlements. Yet, when the contract with the company was terminated, the same TPAs were retained by the SHA and are still working.

The report also expressed serious concern over the fact that the insurance company was issued termination order even when the number of patients getting treatment under the scheme in private hospitals was increasing every month. The termination order mainly talks about many hospitals denying the treatment to the beneficiaries. However, the record reveals that the pre-authorisation for the treatment showed an increasing trend.

BENEFICIARIES INCREASED YET CONTRACT ENDED

• In Nov and Dec 2021, approximately 50,000 new claims per month were submitted, while the insurer settled 75,000 claims monthly
• Similarly, the insurer paid claims worth almost Rs 180 cr, which is way higher than the premium paid to the SBI-GIC, during the two months
• Average claim settlement period, which was 50 days initially, came down to 17 days in three fortnights before the termination order was issued

GUILTY TO FACE ACTION

I am examining the report and an appropriate action will be taken against the officials responsible for making the public suffer. — Vijay Kumar Janjua, Chief Secretary