Imagine going to the Goa Medical College (GMC) at Bambolim for a major operation with your Deen Dayal Swasthya Seva Yojana (DDSSY) insurance card, only to be told that you cannot avail the government’s cashless health insurance scheme, despite your operation procedure being covered under it. This isn’t some nightmare, but has happened to a man recently, who underwent this traumatic experience.
A news report that I read recently said, “Medical protection plays a key role in out-of-pocket expenditure that any population has to bear. And, according to World Bank data, in India, the out-of-pocket expenditure on healthcare for 2012 stood at 86 per cent. This means that 86 per cent of India’s population has to depend on its own income instead of health insurance or government aid to meet health expenses.” For Goans, the DDSSY is the government’s subsidised insurance to tackle and ease the out-of-pocket expenditure.
The scheme offers cashless health insurance to meet the expenses of hospitalisation for medical or surgical procedures. Under it, 447 procedures are covered and it has tie ups with various private hospitals. Card holders can avail cashless hospitalisation up to Rs 2.5 lakh for a family up to 3 members and up to Rs 4 lakh maximum for a family of four or more members. It received positive press coverage in the state and was touted as the mother of all schemes when the Goa government rolled it out.
The government of Goa has been encouraging its citizens to avail it, lauding it as a shining example of a successful welfare scheme. A news report stated Health Minister Francis D’Souza saying, “Since September 1, 2016, highest claims under the scheme have been approved by the GMC hospital numbering 250, while those settled by private hospitals during the same period are 142 at the Manipal Hospital Goa, followed by 87 at the Apollo Victor Hospital, among others.”
But has it passed the litmus test. I am not so sure. You see, the DDSSY is a good component of social protection, but it can only be termed successful when the end user can avail the full benefits it claims to provide. The scheme in its present form is a mess and inefficient. The reason being, people availing the scheme at GMC have had to make advance payments, despite it being a cashless policy. Why should an insured individual have to make an advance payment? It is contradictory to the essence of a cashless policy.
The case that I am referring is one that we are in the know of. There could be many such cases, that haven’t come to the fore. Where do patients from the poor strata go to complain; and if they do, the procedures to follow are killing. The person in question, had his wife show his card at the DDSSY counter in GMC, before the operation; the DDSSY representatives refused to accept the card. The patient was then told to pay the full amount of the surgery before it was conducted. After the surgery, the wife again produced the DDSSY card. This time too, she was turned down. The reason, “She had booked a private room in GMC.” What has the booking of a private room got to do with reimbursing or paying for medicines, investigations, doctor charges, operation etc.? There seem to be no logic in what the DDSSY centre put forth.
I intervened and spoke to the DDSSY representatives about what are the procedures we needed to follow. It came to light that they themselves were unaware as to what needs to be done. We called up the helpline and visited the office too, but no one in the DDSSY seems to know the procedure. The only response we got is, “You should show the card before you admit yourself and the representatives will guide you.” But when the card was shown, it was turned down. To clear our doubts, we put forth the case in the state health department. Their answer too was, “We will check and get back to you,” till date we are awaiting their response.”
I decided further to check on the clauses put forth by DDSSY representatives with a top official in GMC and a reputed doctor. The official and doctor both agreed, that there is a ‘misunderstanding’ as booking a private room has nothing to do with reimbursing the money spent on medication, investigations etc.
The DDSSY centre, suddenly decides to accept the card, but informs us that they would not reimburse the amount to us, but will credit the same to GMC’s account. Why should the amount be credited to GMC, when the lady had already paid the full amount in cash to GMC before the operation. This means GMC receives cash from the patient and from the DDSSY scheme.
Our woes did not end here and we were in for another shock, which is completely unacceptable. While deducting the amount from the card, instead of deducting the exact amount, DDSSY deducted an amount 400 times higher than the actual amount. On being questioned we were told that, this is the procedure. Another major anomaly in the system.
One cannot understand, why a cashless policy, needs a patient to run around to avail the scheme. The process should be between hospital and insurance company, like any other medical insurance card. What happens to citizens who have the card and do not know the real procedures? It is unfortunate that the government while creating this scheme looked at it, as a political ploy as elections are around the corner to win votes. The DDSSY scheme instead of enabling citizens to enjoy medical treatment at a low rate only seems to be forcing them to gamble with their health and lives.
(The author is Managing
Director of Aviation Travel & Tourism Services)
