Srinagar- Ineligible beneficiaries, money disbursed for the treatment in the name of deceased person, out-of-pocket expenditure and no recovery of penalties: these are some of the irregularities found by the Comptroller and Auditor General (CAG) of India in government’s much hyped Pradhan Mantri Jan Arogya Yojana (PMJAY) health insurance scheme in Jammu and Kashmir.
According to the CAG report, a copy of which lies with Kashmir Observer, the PMJAY scheme in the Union Territory is marred with irregularities and measures have been suggested to the Union Territory administration to bring an end to financial discrepancies.
AB-PMJAY was launched on 23 September 2018.
The scheme aims to provide health cover of Rs 5 lakh per family per year for secondary and tertiary care hospitalization to over 10.741 crore families from the poor and vulnerable section of the population, based on the deprivation and occupational criteria of the Socio- Economic Caste Census (SECC), 2011.
The aim is to improve affordability, accessibility, and quality of care for the poor and vulnerable section of the population.
The scheme has been launched for achieving a significant reduction in out-of-pocket expenditure due to health care costs and achieving reduction in proportion of households experiencing catastrophic health expenditures and consequent impoverishment. The eligible beneficiaries are entitled under AB-PMJAY for cashless and paperless access to services at the empanelled hospitals.
The report of the CAG contains results of the Performance Audit on AB-PMJAY covering the period September 2018 to March 2021.
Audit noted that the PMJAY Scheme, an ambitious and well-intentioned programme to provide healthcare access to most vulnerable sections in the country, has had a strong positive impact on the economically weaker sections of the society who need healthcare facilities. However, the implementation of the scheme needs improvement in the light of the findings made in the report.
“It is expected that the compliance to the observations and recommendations made in this report will help in improving the implementation of the scheme,” it noted.
According to the report, in Jammu & Kashmir and Ladakh, during the period 2018 to 2021, 16865 and 335 numbers of ineligible beneficiaries respectively were identified by SHA (state health authority) after clearing the SECC data, thus indicating the existence of ineligible beneficiaries in the SECC database.
The report revealed that 15 hospitals were empanelled with delay. The CAG report further stated that in Jammu and Kashmir, 4, 97,358 cases were rejected and the maximum delay in days was 404.
The report further reveals that Rs 10.96 lakh were disbursed for the treatment of 48 patients who had previously been declared deceased in the scheme’s database in Jammu and Kashmir.
Under the CAG’s performance audit, it was found that In Jammu and Kashmir, (459) beneficiaries were charged for their treatment in empanelled Health Care Providers (EHCPs) resulting in an increase in out-of-pocket expenditure of beneficiaries.
Data analysis revealed that SHAs of Jammu & Kashmir and Ladakh failed to levy penalties amounting to Rs 20.93 crore and Rs 39.66 lakh respectively on Insurer for non-performance of various activities.
Penalty amounting to Rs 12.32 crore from 100 hospitals was pending in nine States/UTs. SHAs Jammu & Kashmir and Ladakh failed to levy penalties amounting to Rs 20.93 crore and Rs 39.66 lakh respectively on Insurer for non-performance of various activities.
“Since no penalties were levied by the SHAs, no such recoveries were made from the defaulting hospitals, thereby not deterring the hospitals from deviating from the performance indicators specified under the scheme,” the report said.
Further, due to delay in payment of premium to the Insurance Company up to 161 days under Contract Agreement (PS–4), SHA, Jammu & Kashmir failed to recover a penalty of Rs 2.91 crore on account of delayed claim payments from the Insurance Company.
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