GST on health services in India

Introduction

Everything else comes second to health, according to the proverb “Health is Wealth,” which suggests that when a person maintains excellent health, everything else falls into place. The central government has exempted health care services from the GST charge in recognition of the value of health and the services provided by the health service industry, making them more accessible to the general public. In this post, I would be discussing various health care exemptions provided by the Central Government and how a person can take such tax benefits.

The Central Board of Indirect Taxes vide Entry 74 of Notification 12/2017 has exempted Health care services by a clinical establishment, an authorised medical practitioner or para-medics.

Definition of Health Care Services

The term ‘health care services’ is defined as follows:

Health care services means

• any service by way of diagnosis or treatment or care for illness, injury, deformity, abnormality or pregnancy in any recognised system of medicines in India; and
• includes services by way of transportation of the patient to and from a clinical establishment, but
• does not include hair transplant or cosmetic or plastic surgery, except when undertaken to restore or to reconstruct anatomy or functions of body affected due to congenital defects, developmental abnormalities, injury or trauma.

Example;-   XYZ Nursing Home specializes in undertaking plastic surgeries. One such surgery is conducted to repair cleft lip of a new born baby. In view of above definition, plastic surgeries are not included in health care services. However, plastic surgery conducted to repair a cleft lip will be included in health care services as it reconstructs anatomy or functions of body affected due to congenital defects (i.e. cleft lip).

Example; – ABC Multispecialty Hospital provides palliative care to patients facing serious and life-threatening illness. Palliative care is given to improve the quality of life of patients who have a serious or life-threatening disease, but the goal of such care is not to cure the disease. On request, such care is also provided to patients at their homes. Health care service means any service by way of diagnosis or treatment or care for illness, injury, deformity, abnormality or pregnancy in any recognized system of medicines in India. 

Place of Provision of Health Care Service

It is immaterial whether such service is provided at the clinical establishment or at the home of the patient or at any other place. Thus, palliative care for terminally ill patients provided at their homes is included in health care services.

Identifying health care services which are exempted

 As it is apparent from the definition of health care services, only services in recognized systems of medicines in India are exempt under this entry.

Following systems of medicines are the recognized systems of medicines in India:-

1. Allopathy

2. Yoga

3. Naturopathy

4. Ayurveda

5. Homeopathy

6. Siddha

7. Unani

8. Any other system of medicine that may be recognized by Central Government.

Example- Reiki healing treatment is not a recognized system of medicines. Therefore, it is not included in health care services.

 Definition of the term clinical establishment/ authorised medical practitioner and paramedics

Let us now understand the meaning of terms – ‘clinical establishment’, ‘authorised medical practitioner’ and ‘paramedics’.

Clinical establishment: means a hospital, nursing home, clinic, sanatorium or any other institution by, whatever name called, that offers services or facilities requiring diagnosis or treatment or care for illness, injury, deformity, abnormality or pregnancy in any recognised system of medicines in India, or a place established as an independent entity or a part of an establishment to carry out diagnostic or investigative services of diseases.

Thus, diagnostic or investigative services of diseases provided by pathological labs are not liable to GST.

Authorised medical practitioner: means a medical practitioner registered with any of the councils of recognised system of medicines established/recognised by law in India & includes a medical professional having requisite qualification to practice in any recognised system of medicines in India as per any law for the time being in force.

Paramedics: Paramedics are trained health care professionals, for example, nursing staff, physiotherapists, technicians, lab assistants etc. Services by them in a clinical establishment would be in the capacity of employee and not provided in independent capacity and will thus be considered as services by such clinical establishment. Similar services in independent capacity are also exempted. In other words, the services provided by para medics in their individual capacity will be exempted.

Ancillary services provided by Hospitals

1. Rent of rooms provided to in-patients

Rent of rooms provided to in-patients in hospitals is exempt [Circular No. 27/01/2018 GST dated 04.01.2018].

2.  Services provided by senior doctors/ consultants/ technicians

1. Hospitals hire senior doctors/ consultants/ technicians independently. Such persons do not have any contract with the patient. Hospitals pay them consultancy charges and there is no employer-employee relationship between them.

2. It is clarified by CBIC that services provided by such senior doctors/ consultants/ technicians, whether employees or not, are healthcare services which are exempt from GST [Circular No. 32/06/2018 GST dated 12.02.2018].

3. Amount charged by hospitals from the patients

In above cases, suppose hospitals charge the patients, say, ` 10,000/- and pay to the consultants/technicians only ` 7,500/- and keep the balance for providing ancillary services which include nursing care, infrastructure facilities, paramedic care, emergency services, checking of temperature, weight, blood pressure, etc.

Going through the definition of health care services [given above], it can be inferred those hospitals also provide healthcare services.

The entire amount charged by them from the patients including the retention money and the fee/payments made to the doctors etc., is towards the healthcare services provided by the hospitals to the patients and is exempt [Circular No. 32/06/2018 GST dated 12.02.2018].

4. Food supplied to the patients

Health care services provided by the clinical establishments will include food supplied to the patients; but such food may be prepared by the canteens run by the hospitals or may be outsourced by the hospitals from outdoor caterers.

When outsourced, there is no ambiguity that the suppliers shall charge tax as applicable and hospital will get no ITC.

Food supplied to the in-patients as advised by the doctor/nutritionists is a part of composite supply of healthcare and not separately taxable.

Other supplies of food by a hospital to patients (not admitted) or their attendants or visitors are taxable [Circular No. 32/06/2018 GST dated 12.02.2018].

5. Ambulance facilities provided by hospitals

Ambulance services provided National Health Mission (NHM)

National Health Mission (NHM) is a flagship programme of the Government of India wherein the Central Government provides technical and financial support to States to strengthen healthcare systems including for free ambulance services (Dial 102/108 services).

Dial 108 is the emergency response system primarily designed to attend to patients of critical care, trauma and accident victims etc. while Dial 102 services essentially are for basic patient transport aimed to cater the needs of pregnant women and children, though other categories are also taking benefit and are not excluded.

Some State Governments themselves provide the free ambulance services to the patients while many States are operating the ambulance service on an outsourced model, i.e., services are provided by a private service provider (PSP) on behalf of State Government and it charges a fee from the State Governments for said ambulance services. However, in both the cases, ambulance services are provided free of cost to the patients.

Services provided by State Governments and Private Service Providers (PSPs) by way of transportation of patients in ambulance are exempt under Entry 74 above.

 As regards ambulance services provided by PSPs [under NHM] on behalf of State Governments against consideration in the form of fee or otherwise charged from State Government, since ambulance services are an activity in relation to ‘health and sanitation’ and ‘public health’ functions entrusted to Panchayats and Municipalities under Article 243G and 243W of the Constitution of India, same would be exempt as under:

Entry 3 if it is a pure service and not a composite supply involving supply of any goods, and

Entry 3A if it is a composite supply of goods and services in which the value of supply of goods constitutes not more than 25% of the value of the said composite supply [Circular No. 51/25/2018 GST dated 31.07.2018]. [Refer Entry 3 and 3A discussed in detail subsequently under heading ‘Services provided to Government’].

Services other than health care services in clinical establishment’s premises

Supply of services other than healthcare services such as renting of shops, auditoriums in the premises of the clinical establishment, display of advertisements etc. will be subject to GST.

Conclusion

The view taken in the preceding paras, that health care services coupled with other incidental services is a composite supply and is exempt since the principal supply [health care service] is exempt, is based on Circular No. 32/06/2018 GST dated 12.02.2018. However, it is also possible to take a different view since as per the definition of composite supply under section 2(30) of the CGST Act, composite supply consists of two or more taxable supplies.