J&K Govt clarifies PMJAY-SEHAT Scheme implementation amidst misinformation

JAMMU, October 14: In a press conference held today, the Secretary Health and Medical Education, Bhupinder Kumar has addressed concerns and allegations surrounding the implementation of the Pradhan Mantri Jan Arogya Yojana – SEHAT (PMJAY-SEHAT) scheme.

One of the key allegations was related to a loss of Rs. 500 Crores. The government clarified that the total premium paid to Bajaj Allianz General Insurance Company (BAGIC) during the policy period from December 26, 2020, to March 14, 2022, was Rs. 304.59 Crores, while the total claims payout to hospitals (both public and private) by BAGIC was Rs. 398.41 Crores. Consequently, the allegation of a loss is unsubstantiated as the insurance company incurred a monetary loss of Rs. 93.82 Crores.

Misinformation about the termination clause and contract renewal has also surfaced. According to the contract between BAGIC and the State Health Agency, the maximum term was fixed for three years and renewable every 12 months. The continuation of the contract beyond the first year was to be based on mutual agreement, and the insurance company decided to exit after the first year due to incurred losses.

To avoid service interruption, the State Health Agency of J&K entered into an interim arrangement with BAGIC on a Stop Loss basis until a new insurance company was selected. During this period, the government bore the entire risk of loss of claims. The arrangement was cost-effective and served the public interest by ensuring the continuity of healthcare services.

Contrary to allegations that the number of eligible families was increased to benefit the insurance company, the government clarified that the number of families remained the same during the policy period, from December 26, 2020, to December 25, 2021, and the subsequent interim period of 79 days, totaling 21.24 lakhs.

The Government of Jammu and Kashmir emphasized its adherence to the guidelines of the National Health Authority (NHA), Government of India, for the scheme’s implementation. This includes the use of the Model Tender Document for the transparent selection of insurance companies and the adoption of Health Benefits Packages (2.2 version) for implementation.

Since the launch of the PMJAY-SEHAT scheme, the government has paid Rs. 1175.32 Crores in premiums to insurance companies. In return, insurance companies disbursed a total of Rs. 1,249.33 Crores in claims to empaneled hospitals, benefiting approximately 5.67 lakh patients. The scheme has provided crucial medical care for patients with life-consuming and life-threatening diseases.

The insurance model has shifted the risk to insurance companies, leading them to pay nearly Rs. 74 Crores beyond the premium to empaneled public and private hospitals. This model has strengthened the healthcare system within the UT and significantly reduced out-of-pocket expenses for families in need of hospitalization.

Additionally, a feedback system using QR codes and a 104 Call Centre has been implemented, with nearly 99% of patients rating their treatment experience as Excellent or Good.

The government emphasized that allegations intended to discredit the scheme are baseless, false, and aimed at maligning its image. It reiterated its commitment to providing quality healthcare services to the public.

Divisional Commissioner Jammu Ramesh Kumar, Additional Secretary in Chief Secretary office, Vishal Sharma, Joint Director HQ Information, Naresh Kumar, Deputy Director Information PR Jammu, Dr. Vikas Sharma were also present during the press conference.