The Jammu & Kashmir’s much-appreciated health insurance scheme (Golden Card), launched in 2020, is losing its sheen day by day. Initially, there was a legal tussle between the government and the insurance company. Now, the issue is about reserving certain surgical procedures to be done only in government hospitals. The PM and LG Administration had received much appreciation for this public welfare health program, but due to various reasons, the Golden Card scheme may not benefit the poor in the months to come.
Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PM-JAY), commonly known as the Golden Card scheme, was launched around December 2018 in Jammu & Kashmir. This is a medical insurance scheme meant to benefit only the poor population living under the Below Poverty Line (BPL). By the end of 2020, this scheme was renamed the AB-PM-JAY SEHAT scheme, and its benefits were extended to all 20 lakh families living in J&K. The scheme was formally launched by Prime Minister Modi on December 26, 2020.
What is this scheme all about?
The main focus of Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (PMJAY) – SEHAT scheme is protection from catastrophic health expenditures. According to the State Health Agency (SHA), this scheme is delivered through both public and private healthcare providers for providing secondary and tertiary care health services.
- The scheme provides a cover of Rs. 5 lakh per family per year. All medical and surgical conditions are included with minimal exclusions.
- It covers both pre- and post-hospitalization expenses.
- All pre-existing conditions are covered from day one.
- There is no family size or age limit.
- Public hospitals are deemed empanelled, while private healthcare facilities have been empanelled based on defined criteria (including specialty-specific criteria).
How did the problem start?
Bajaj Allianz GIC was the implementing agency for Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (PMJAY) and AB PM-JAY SEHAT in Jammu & Kashmir until 2022. After the contract ended with Bajaj Allianz, IFFCO-TOKIO General Insurance Company signed the contract with the State Health Agency (SHA) in November 2023. The contract, which came into effect on March 10, 2022, was supposed to continue for three years (until March 2025). However, IFFCO TOKIO, according to media reports, suffered financial losses and ended the contract much before its expiry date. The State Health Agency (SHA) requested IFFCO-TOKIO to continue the contract “in the interest of patient care,” but the company refused.
SHA moved to the High Court
As the company was unable to continue its work, the State Health Agency (SHA) sought judicial intervention by filing a writ petition against IFFCO-TOKIO in the Jammu & Kashmir High Court. SHA requested the court to stay the termination of the contract and order the insurance company to fulfill the contract until its expiry on March 14, 2025, citing the importance of “patient care” and public well-being. The SHA also urged the court to direct the company to refrain from opting out of the contract. In September last year, the High Court directed the J&K government to utilize a premium amount of Rs. 427.73 crores lying with it for reimbursement of medical claims.
The division bench of Justice Sanjeev Kumar and Justice Sindhu Sharma, however, said that reimbursement of the premium amount would be subject to the outcome of an appeal filed by IFFCO Tokio General Insurance Co. Ltd against an order by the court’s single bench, which had earlier asked the company to continue with the existing arrangement. This order helped service providers (private hospitals) receive payments that had been held up for the last few years. As this issue started getting addressed, another issue regarding the health insurance scheme arose: the government, according to media reports, plans to exclude some surgical procedures under the ABPMJAY SEHAT scheme.
Excluding Some Surgical Procedures
Four surgical procedures—cholecystectomy, hemorrhoidectomy, appendectomy, and fissure surgery—are said to be excluded from the ABPMJAY SEHAT scheme, and they will no longer be covered in private hospitals starting from March 15, 2025. This is a major policy shift under active consideration by the government. This change will lead to prolonged waiting times in government-run hospitals. It is a known fact that for smaller surgical procedures, like fissures or piles, one has to wait for months to get the surgery done. Once private hospitals are exempted from these procedures, it will directly impact poor patients. The wealthy will go to private hospitals and pay the surgical charges, but where will poor patients go? The J&K Chief Secretary, Atal Dulloo, chaired the 9th Governing Council Meeting of the State Health Agency (SHA) on January 19, 2025, and it is said that this decision was taken in that meeting.
Decision Against the Private Sector
The decision taken during the governing council meeting, chaired by the Chief Secretary, is not only against poor patients but also against the interests of private hospitals. It is a known fact that private hospitals providing Golden Card services have already suffered a lot in the past 10 months due to the legal tussle between the State Health Agency (SHA) and Insurance Company IFFCO TOKIO. In the governing council meeting, nothing was decided regarding the release of long-pending payments to these service providers, 1% interest for the delayed payments, or other issues. The Private Hospital Association has written to the government and believes that the contract with the State Health Agency, after the completion of the three-year term starting on March 15, 2025, can no longer be tenable, as it won’t be possible for them to meet the expenses at the diminishing rates, especially with delayed payments.
“Neither have the packages been revised, even after the Union Government’s enhancement of the budget for the Ayushman Bharat scheme by 24%, raising it to Rs. 9,406 crores,” reads a representation from the Private Hospitals and Dialysis Centre Association.
Conclusion
To make the Golden Card health insurance scheme viable, the government must increase the budget allocation from the current Rs. 589 crores to Rs. 900-950 crores for the smooth running of the AB-PMJAY SEHAT scheme in J&K. There should be no reservations for any surgical procedures to be done in private hospitals, as the right to health is a constitutional right guaranteed under Article 21 of the Constitution. Chief Minister Omar Abdullah and Health Minister Sakina Masood must intervene personally because this will not only impact the economically weaker sections of society but also give a significant jolt to the National Conference politically.
- Views expressed in the article are the author’s own and do not necessarily represent the editorial stance of Kashmir Observer
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