During my earlier stint when I was in UAE and Abu Dhabi in specific, I was made in charge of the Insurance department of the company where I worked and I had acquired good practical knowledge since medical insurance is compulsory in the Emirate of Abu Dhabi and our company had a strength of nearly 3500 Blue collared staff and 350 White-collared staff in the Abu Dhabi operations, as a rule, the blue collared ones were covered by the standard cheaper Daman insurance and the white collars were covered by the private insurers in a competitive bid process where competition amongst the different insurance companies was intense to bag our Corporate account.
Daman insurance was widely accepted covering both OPD & Inpatient, in some of the major hospitals you had a separate clinic for Daman Card Holders and, it was a win-win situation for all the concerned parties. The white collars were separately covered on a yearly basis having specific geographic coverage, organ transplantation and it also included the cost of domiciliary treatment benefits including regular medicines for diabetes and hypertension up to certain limits as laid down by the insurance company which used to monitor the claims on a yearly basis as against the premium paid and they used to arrive at a mutually beneficial price for the corporate account taking in to account other aspects of insurance businesses like Fire, Stock, Marine, Indemnity, Property, etc.
So when I came back and settled back in India I found that the health insurance sector in India is not covered much because of our own negligence, we go to hospitals only in case of emergencies and I doubt very much if anybody goes out on their own even to get even basic diagnostic tests done at least once in a year which can easily prevent a person from high medical costs at a later period because we try to downplay health-related issues here in India with respect to the ailments and are constantly in denial mode until the medical problem erupts like a volcano.
Recently Two people known to me had a medical emergency which landed up with a bill of almost Rs 1.00 million in one case and Rs 2.6 million in another case in corporate hospitals in the city of Bengaluru and both lost their lives despite spending a huge amount on medical emergencies and in both the cases the medical expenses were partly covered by insurance and the majority part was funded by their own personal savings. What I find strange is that people tend to buy a policy only when there is a medical emergency and everybody knows very well that there is a waiting period for any insurance policy to come into effect. Health insurance costs more in the Metros as compared to Tier2 or Tier 3 Cities in India.
Health insurance is a state subject which is not been given its due, According to a report of Niti Ayog India has nearly 30% or 42 crore of its population devoid of any health insurance with actual numbers being higher due to gaps in the existing scheme and overlap between the schemes, the NITI Aayog has said, suggesting the need for a low-cost health insurance product for this section of the population if India aims to achieve universal health coverage.
PM-JAY is a very good scheme covering the lower start of the society having BPL Cards but the problem is the middle class is not covered by this scheme and is estimated that nearly 42 crores people are left out of any coverage and this is a problem even for a good earning middle-class employee, let me draw some schemes from my home state Karnataka which has slowly getting acquainted with the insurance policies and schemes as of now.
CASHLESS FACILITIES OF GOVT. HEALTH INSURANCE SCHEMES
- Arogya Bhagya Yojana for Police Personnel
- ESI Facility for Secondary and Tertiary Treatment
- ITDP Scheme for Koraga Samudaya
- Jyothi Sanjivini Scheme for State Govt. Employees
- Mukyamanthri Arogya Scheme for CMC Staff of Udupi
- Arogya Karnataka
REIMBURSEMENT
- Chaithanya Arogya Yojana of Navodaya Group
- Indian Railways
- Reimbursement Facility for State Govt. Employees
So to fill the gap of 42 crores of missing population Arogya Sanjeevani was launched On 01-04-2020 with the blessings of IRDAI and according to my overall analysis, this scheme suffers from a lot of disadvantages rather than the advantages when we speak about this scheme, so IRDAI has to take immediate steps to correct so many procedural issues before making this scheme acceptable & Successful to one and all and so that everybody benefits from the universal health insurance policies without being a burden on our own pockets.
Exclusions of Arogya Sanjeevani Policy
The Arogya Sanjeevani Health Plan does not include the following treatments or situations:
Diagnostic or Investigative Tests – It will not cover the expenses incurred on getting any diagnostic or investigative tests done meaning your MRI, Scan tests, Blood tests, Routine tests will not be covered
Bed Rest or Rehabilitation Expenses – It will not cover any expenses incurred due to enforced bed rest in the absence of treatment. It will also not cover any expenses arising out of rehabilitation needs means if a person has met with an accident or any other issue, his bed rest including home care and physiotherapy will not be covered, if the person is salaried and he is bedridden even the compensatory salary may not be paid as per my understanding.
Weight Control / Obesity Treatment – Any expenses arising out of the treatment taken for obesity or weight management will not be covered this was not covered in UAE too.
Gender-change Treatment – It will not cover the cost of taking any treatment for changing the gender this was not covered in UAE too.
Cosmetic or Plastic Surgery – Any expenses incurred on cosmetic or plastic surgery which is not required as a result of an accident, cancer, burn injury, or medically necessary treatment will not be covered. Same as above.
Maternity Expenses – It will not cover the cost of any treatment related to pregnancy and childbirth. I do not know the reason why this has been excluded because it is a normal occurrence maybe they fear that delivery by C-Section will be more expensive than the normal delivery but the insurance company can set a ceiling of Rs 90 K per C-Section for a maximum of 2 Deliveries.
OPD Treatment – It will not cover the cost of any OPD or outpatient treatment taken by the policyholder. This will defeat the very purpose of the insurance card, in the majority of the cases it will be OPD Or Day Care and this scheme has to include the same.
Adventure/ Hazardous Sports – Under this medical insurance does not cover any medical treatment expenses arising due to participation in hazardous or adventure sports, such as rock climbing, sky diving, para-jumping, deep-sea diving, mountaineering, etc, as a professional. Even this scheme is excluded in UAE.
Breach of Law – It will not cover any expenses incurred due to breaching the law with a criminal intention same holds true even in UAE.
Alcohol/ Drug addiction – Any expenses arising out of the treatment for addiction of alcohol or drug or substance abuse will not be covered. As above
Dietary Supplements – It will not cover the cost of purchasing any dietary substance or supplements, such as minerals, vitamins, etc., without a prescription. As above
Unproven Treatment – This policy will not cover the cost of any unproven treatment taken by the policyholder. Same as above
Infertility and Sterility – It will not cover any expenses arising out of infertility or sterility. Same as above, IVF is not covered by the insurance companies even in UAE and this is an expensive deal along with Dental Coverage which is also too expensive. A simple root canal will cost AED 12,000 equivalent to Rs 240,000 whereas in my place the cost will be around Rs 12,000 with 4-6 sittings.
Domiciliary hospitalization – Any expenses arising out of domiciliary hospitalization will not be covered, if you ask me this has to be covered, once the doctor advised me to take antibiotics in liquid form and I had to take a room at least for some hours to administer through the intravenous method and if normal rooms were not available they used to give the same in VIP rooms which were out of the world FOC.
Nuclear attack or War – This policy will not cover any claims arising out of a nuclear attack or a war/ war-like situation. This is excluded even in UAE
Treatment outside India – It will not cover the expenses incurred on receiving any outside India. In UAE, they were allowing treatment in India subject to prior approval from the insurance company as they feel getting the same treatment in India is cheaper than UAE.
The Arogya Sanjeevani Health Policy comes with the following waiting periods:
Initial Waiting Period – An initial waiting period of 30 days from the date of policy commencement for all claims except accidental claims.
Pre-Existing Disease – A waiting period of 4 years for coverage of pre-existing disease or medical condition.
Specific Illness/ Treatment – A waiting period of 2/ 4 years for coverage of specific treatments such as tonsillectomy, benign prostate hypertrophy, hernia, cataract, internal congenital anomalies, age-related osteoporosis/ osteoarthritis, joint replacement treatment, etc.
This is a major drawback and this scheme will fail because of this waiting period, this has to be removed to gain further market share.
Conclusion :
Since the Government of India collects 4 % health and education cess since it was first introduced in The Finance Act of the year 2004 from all the taxpayers I have a very good suggestion, file your ITR and take benefits of PMJAY automatically because the honest taxpayers are generally the middle-class people, make a system in the ITR filing process to issue the health care for the person who is filing his annual return properly and make a provision to add the dependants if he is the head of the family, automatically you can bring many people into ITR network too without much effort and everybody benefits from the same. This scheme should be extended to senior citizens too as the premium for individuals under senior citizens is pricey which can be more than Rs 80,000 which is simply prohibitive for senior citizens with frugal resources. We have one scheme in our area known as the Manipal card which has select acceptance only in select hospitals of the Manipal group (KMC)in our Area ( DK & Udupi Districts ) and does not cover Bengaluru which also covers Pregnancy and offers huge discounts on OPD Fees and I will vouch for their efficiency and efficacy. So if there is a will there is a way.
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