Health insurance for pensioners
Allowing the profit motive to exist in health-care system is the real travesty. A mockery of Article 21, read with Article 39(e), 41,43,48A of the constitution of India .
The marketing stratagy of every Private company is to initially provide quality
Servic e/produc t at a cheaper cost to make beneficiaries addicted to it & then to go on goofing the cost & reducing the qulity, as they work for profits.
By its very nature, any for-profit business, will try to maximize its bottom line. If a company doesn’t focus effectively on making a profit, it will go out of business. But there are some kinds of services for which the for-profit model is clearly the wrong one. Take, for instance, policing. How well would it work if you had to rely on a group of competing local businesses to fight crime and provide public security? Surely such matters are not the place for competition and profit making. Enlightened societies recognize that public safety is a common good—a human right—and that it doesn’t belong in the hands of protection rackets.
Health care should be treated the same way: as a common good, a human right. The problem with for-profit medical insurance is that business imperatives are too often in direct conflict with those basic goods.
In developed european countries the profibilty of Health insurance is around 4% and with which it is difficult for them to sustain, that is why with the pressure of world Bank they have targetted the Indian Market.
Even in developed European countries, those who have coverage of health insurance are seeing their premiums rise, their benefits cut, and their relationship with their doctors interfered with by insurance company/TPA . There is often a long wait for approval or denial for those with pre-existing conditions.
At present ‘Heath Insurance’ in India too, is a loosing bussiness .Already the cashless treatment is under dispute.Insurance Companies are demanding higher premium corresponding to the cost of treatment & other services. In the coming days there is bound to be nexus between isurrance providers ,TPAs & The Hospitals, resulting in higher & higher premiums & inferior services.
In India the law is well settled, in the Apex court judgment in the case of Consumer Education & Research Center & others v/s UOI & others in writ petition (C) No.206 of 1986 {AIR 95 Vol. 82 Page922} Para 27 wherein the honorable S.C. ruled ”we therefore hold that right to medical aid to protect the health & vigor of a worker while in service or post retirement is Fundamental Right under Article 21, read with Article 39(e), 41,43,48A and all the related articles and Fundamental human rights to make the life of the workman meaningful and purposeful with dignity of person.” In another land mark Judgement, the Supreme court has made providers of medical facilities also a subject to the Consumer protection Act 1986 .In Indian Medical Association vs V.P. Shantha and others (1995(6) SSC.651 ) (Para114.6 of 5th CPC report) Recently also Delhi H.C in , W.P.(C) 889/2007 ,DOJ: 12.3.2010, Kishan Chand. Versus Govt. of N.C.T. & Others, has ruled “It is a settled legal position that a government employee, during his life time (read service life) or after his retirement is entitled to get medical reimbursement and no fetters can be placed on his rights on the pretext that he has not opted to become a member of any scheme” . This means government must bear the complete financial burden of Health care to its present as well as past employees.
The proposed Health Insurance Scheme for the employees / Pensioners provide coverage of Rs 5lakhs to a family of six i.e Self ,Spouse, Two dependent Children plus upto two dependents parents.(all other dependent relatives are excluded) additional premium shall have to be paid for the inclusion of each of the other eligible dependent relatives.
There will be two scenarios!
Ist Scenario: The Scheme shall provide coverage for meeting all expenses relating to hospitalization of beneficiary members up to Rs. 5, 00,000/- per family per year in any of the Empanelled Hospital/Nursing Home/Day Care Unit subject to stated limits on cashless basis through smart cards. The benefit shall be available to each and every member of the family on floater basis i.e. the total reimbursement of Rs. 5.00 lakh can be availed by one individual or collectively by all members of the family. Suppose ; in the very first month of joining, God forbids, one of the family members gets an Heart attack.5lakhs coverage will go just in one stroke. Then what will happen to other members, if they happen to need major surgeries during the rest of the policy period? Reimbursement? will be much more difficult as it is today and will give rise to corruption/spate of Court cases! Pensioners share of premium will be to the tone of Rs 800/ to 1000/ per month may be more, w/o any safe guard against future increase, which will drill a deep hole in poor pensioner’s pocket. Picture the case of a family pensioner with minimum pension /a ‘D’ group pensioner. How a pensioner or a family pensioner with a meager Pension of Rs 3500 plus DR is going to afford, is any body’s guess.!
Second scenario: Insurance providers for their own survival will be interested in profits and more & more of it, this will result in premium rise, cut in quality & quantity of service, inordinate delays in approval, interference in Doctor-patient relation ship . Will induce corruption. The situation will be worst than the Govt. District Hospitals! That is why 5th CPC in their Para 114.12 of the report recommended that “CGHS facility should not only continue but to be expanded”
The way out :
1) Strengthen, expand & improve RELHS,CGHS & ECHS. To expand coverage area, Pool together the infrastructure of these Scheme, revise upwards CGHS rates to suit workability as per market conditions and out source emergency,specialize treatment and diagnostic investigations.
2) Preventive Health care. To control expenditure launch on war footing “preventive health care” programmes among present & past employees which will in the long run reduce healthcare cost. The resources of supper specialty hospitals which have been allotted low cost lands , assistance of Trade unions & Pensioners associations may be availed for this purpose.
3) Doctor at your door step :
Hospital admission is the most inconvenient option for millions of elderly pensioners due to inaccessible convenient transport, non availability of attendant, preoccupation of other family members & management of domestic affairs. Some people can remember when doctors actually went to their patients’ homes. Unfortunately, those days seem to have gone the way of rotary phones and good old-fashioned typewriters .Due to lack of knowledge, information & non availability of a visiting Doctor, often elderly & their family members get falsely alarmed & rush to the nearby hospitals for emergency care. Once you are in. They make it a real emergency. Whether you need it or not they adopt the costliest process to inflate their bill. If you have complained of chest pain, these super spatiality Hospitals will insert one or two stunts inside your chest.
The marketing stratagy of every Private company is to initially provide quality
Servic e/produc t at a cheaper cost to make beneficiaries addicted to it & then to go on goofing the cost & reducing the qulity, as they work for profits.
By its very nature, any for-profit business, will try to maximize its bottom line. If a company doesn’t focus effectively on making a profit, it will go out of business. But there are some kinds of services for which the for-profit model is clearly the wrong one. Take, for instance, policing. How well would it work if you had to rely on a group of competing local businesses to fight crime and provide public security? Surely such matters are not the place for competition and profit making. Enlightened societies recognize that public safety is a common good—a human right—and that it doesn’t belong in the hands of protection rackets.
Health care should be treated the same way: as a common good, a human right. The problem with for-profit medical insurance is that business imperatives are too often in direct conflict with those basic goods.
In developed european countries the profibilty of Health insurance is around 4% and with which it is difficult for them to sustain, that is why with the pressure of world Bank they have targetted the Indian Market.
Even in developed European countries, those who have coverage of health insurance are seeing their premiums rise, their benefits cut, and their relationship with their doctors interfered with by insurance company/TPA . There is often a long wait for approval or denial for those with pre-existing conditions.
At present ‘Heath Insurance’ in India too, is a loosing bussiness .Already the cashless treatment is under dispute.Insurance Companies are demanding higher premium corresponding to the cost of treatment & other services. In the coming days there is bound to be nexus between isurrance providers ,TPAs & The Hospitals, resulting in higher & higher premiums & inferior services.
In India the law is well settled, in the Apex court judgment in the case of Consumer Education & Research Center & others v/s UOI & others in writ petition (C) No.206 of 1986 {AIR 95 Vol. 82 Page922} Para 27 wherein the honorable S.C. ruled ”we therefore hold that right to medical aid to protect the health & vigor of a worker while in service or post retirement is Fundamental Right under Article 21, read with Article 39(e), 41,43,48A and all the related articles and Fundamental human rights to make the life of the workman meaningful and purposeful with dignity of person.” In another land mark Judgement, the Supreme court has made providers of medical facilities also a subject to the Consumer protection Act 1986 .In Indian Medical Association vs V.P. Shantha and others (1995(6) SSC.651 ) (Para114.6 of 5th CPC report) Recently also Delhi H.C in , W.P.(C) 889/2007 ,DOJ: 12.3.2010, Kishan Chand. Versus Govt. of N.C.T. & Others, has ruled “It is a settled legal position that a government employee, during his life time (read service life) or after his retirement is entitled to get medical reimbursement and no fetters can be placed on his rights on the pretext that he has not opted to become a member of any scheme” . This means government must bear the complete financial burden of Health care to its present as well as past employees.
The proposed Health Insurance Scheme for the employees / Pensioners provide coverage of Rs 5lakhs to a family of six i.e Self ,Spouse, Two dependent Children plus upto two dependents parents.(all other dependent relatives are excluded) additional premium shall have to be paid for the inclusion of each of the other eligible dependent relatives.
There will be two scenarios!
Ist Scenario: The Scheme shall provide coverage for meeting all expenses relating to hospitalization of beneficiary members up to Rs. 5, 00,000/- per family per year in any of the Empanelled Hospital/Nursing Home/Day Care Unit subject to stated limits on cashless basis through smart cards. The benefit shall be available to each and every member of the family on floater basis i.e. the total reimbursement of Rs. 5.00 lakh can be availed by one individual or collectively by all members of the family. Suppose ; in the very first month of joining, God forbids, one of the family members gets an Heart attack.5lakhs coverage will go just in one stroke. Then what will happen to other members, if they happen to need major surgeries during the rest of the policy period? Reimbursement? will be much more difficult as it is today and will give rise to corruption/spate of Court cases! Pensioners share of premium will be to the tone of Rs 800/ to 1000/ per month may be more, w/o any safe guard against future increase, which will drill a deep hole in poor pensioner’s pocket. Picture the case of a family pensioner with minimum pension /a ‘D’ group pensioner. How a pensioner or a family pensioner with a meager Pension of Rs 3500 plus DR is going to afford, is any body’s guess.!
Second scenario: Insurance providers for their own survival will be interested in profits and more & more of it, this will result in premium rise, cut in quality & quantity of service, inordinate delays in approval, interference in Doctor-patient relation ship . Will induce corruption. The situation will be worst than the Govt. District Hospitals! That is why 5th CPC in their Para 114.12 of the report recommended that “CGHS facility should not only continue but to be expanded”
The way out :
1) Strengthen, expand & improve RELHS,CGHS & ECHS. To expand coverage area, Pool together the infrastructure of these Scheme, revise upwards CGHS rates to suit workability as per market conditions and out source emergency,specialize treatment and diagnostic investigations.
2) Preventive Health care. To control expenditure launch on war footing “preventive health care” programmes among present & past employees which will in the long run reduce healthcare cost. The resources of supper specialty hospitals which have been allotted low cost lands , assistance of Trade unions & Pensioners associations may be availed for this purpose.
3) Doctor at your door step :
Hospital admission is the most inconvenient option for millions of elderly pensioners due to inaccessible convenient transport, non availability of attendant, preoccupation of other family members & management of domestic affairs. Some people can remember when doctors actually went to their patients’ homes. Unfortunately, those days seem to have gone the way of rotary phones and good old-fashioned typewriters .Due to lack of knowledge, information & non availability of a visiting Doctor, often elderly & their family members get falsely alarmed & rush to the nearby hospitals for emergency care. Once you are in. They make it a real emergency. Whether you need it or not they adopt the costliest process to inflate their bill. If you have complained of chest pain, these super spatiality Hospitals will insert one or two stunts inside your chest.
A Doctor on call at your door in lieu of a affordable registration fee per family per year plus per visit charges as per pre settled package rates & the cost of good quality generic medicines which the visiting doctor will carry & dispense if required, is the answer to the situation. It will bring down the incidence of hospitalization by at least 50% & will also save the friends & family from lot of inconvenience Modules for such programmes with some Govt. assistance can be developed & implemented
co jointly by the pensioners associations, NGOS & housing Societies.
4) In lieu of dispensation of medicines in OPD Increase FMA to Rs 1000/-Per month &link it to the inflation of medical items. To avoid misuse make stamping of RELHS/CGHS/ECHS card mandatory to show status of disbursement of FMA
This will avoid over crowding, reducing expenditure on local purchase & reducing pilferage of costly medicines, in lieu of dispensing medicines in OPD. This will reduce over crowding ,bring down expenditure on local purchase of medicine, pilferage costly medicines & pressure of workload on Doctors ,thus will be financially viable
(5) Constitute Hospital Advisory & Grievance redress committees at all levels with adequate representation of pensioners.
These measures will not only improve service to the beneficiaries but will also keep Govt expenditure within reasonable limits.
Er.S.C.Maheshwari
Secretary, Bharat Pensioners Samaj
Genl. Secy. RREWA
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