Hospitals confused over Covid-19 claims with no defined package under PMJAY

Centre had said PMJAY would cover Covid-19, but had left it to states to formulate their own packages. Most hospitals are regarding patients as respiratory failure cases for insurance purposes

Even after almost two months of lockdown, many states do not have defined insurance packages to treat Covid-19 under the government’s mass health insurance scheme, Pradhan Mantri Jan Arogya Yojna (PMJAY).

Treatment for Covid-19 is free in government hospitals. However, hospitals, particularly private ones, are finding it difficult to process the treatment claims under PMJAY as there are no defined packages. Most hospitals are blocking Covid1-19 patients as respiratory failure cases.  

In March-end, the Centre had announced that PMJAY would cover the cost of Covid-19 treatment, and had left it to the state governments to formulate their own packages. PMJAY offers 1,393 treatment packages, and states have the liberty to add on to the packages.

According to sources, most of the states are still under the process of getting approvals of the package from NHA. There is no clarity on the number of states which have been able to formulate the package. PMJAY officials could not be reached out for comments.

Jharkhand is one of the few states which has very recently come up with a Covid 19 insurance package under PMJAY. According to a senior official of  Jharkhand health department, expenses up to Rs 7500 per day are covered under the package. For patients who are asymptomatic the cost the coverage is up to about Rs 3500 per day.   In West Bengal, which has not gone for PMJAY, the government has come up with an insurance package of up to Rs 2 lakhs for Covid 19 treatment.

In one of the worst Covid-affected states, Maharashtra too, there is no defined Covid package under PMJAY. However, the state recently had announced that under its own health insurance scheme, Mahatma Jyotiba Phule Jan Arogya Yojana, all the people in the state can avail the benefits of free and cashless health insurance. The state also capped the prices of a number of medical procedures for private and charitable hospitals in the state in order to prevent them from raising charges during the pandemic.

In Punjab too there is no defined package. Only government hospitals in the state have been so far able to block a few Covid 19 under PMJAY.

“There is no specific package for Covid 19, and patients are being blocked under respiratory illness. Private hospitals are confused how to block the cases, and as a result they are reluctant to admit Covid 19 patients,” said a healthcare professional in Punjab.

Notably, under PMJAY, ventilator charges are mostly around Rs 4500 per day. However, in case of Covid, there are additional costs related protective equipment, which can go up to Rs 7000-8000 per day.

“In a scenario of pandemic it is governments duty to fix rates which are reasonable and acceptable for hospitals and common citizens , we need to take into account that this pandemic will not disappear and unless sustainable solutions are found the health infrastructure will not be able to handle rising number of cases,” said a top official of a general insurance firm.

“There is confusion about Covid 19 insurance packages as it is still developing. These are extra ordinary times, and people are  not sure about the cost of treatment. If there is a package, people will at least have an idea about the cost of treatment,” said a senior official of a private insurance firm.  

“In many states, hospitals have no idea what package to claim for Covid 19 and at what is the cost of treatment. The fear of no recovery of such claims and uncertainty of cost of such treatment is adding to the problem,” said a source.