The Comptroller and Auditor General (CAG) has flagged that five general insurance companies providing health insurance coverage under Pradhan Mantri Jan Arogya Yojana (PM-JAY) need to refund Rs 458 crore premium for falling to reach the specified claim-to-premium ratio in five states and one Union Territory.
According to the CAG audit of PM-JAY from 2018-19 till June 2022, in Maharashtra, the National Insurance Company has to refund Rs 214 crore while United India Insurance needs to refund Rs 72 crore. United India Insurance has to refund Rs 111 crore in Tamil Nadu and Oriental Insurance has to refund Rs 55 crore in Gujarat.
PMJAY offers Rs 5,00,000-a-year free health cover to 107 million poor households in the country, roughly covering the bottom 40% population of the country. Under the insurance model, the premium cost is borne in 6:4 ratio by the Centre and states, respectively.
After adjusting a defined percentage for expenses of management (which ranges from 10% to 20%) and after settling all claims, 100% of the surplus should be refunded by the Insurer to the state health agency within 30 days. After 30 days, the insurers will have to pay 1% interest on the refund amount weekly.
As of November 2022, 35.7 million claims amounting to Rs 42,433 crore were settled in both the trust model and insurance model. Out of these, claims amounting to Rs 22,620 crore (53.3%) pertained to the six brownfield States — Andhra Pradesh, Arunachal Pradesh, Rajasthan, Karnataka, Maharashtra and Tamil Nadu. These States use their own IT Platform to process the claims and subsequently feed into the Transaction Management System of PMJAY through an Application Programming Interface (API).
“With no segregation of PMJAY beneficiaries in such cases, there is a possibility of overlap of PMJAY with state specific schemes,” CAG noted.
The National Health Agency, the central agency for PM-JAY, replied that it would seek final settlement statement from all states/UTs implementing the scheme in insurance or mixed mode (insurance and trust models).
Among other issues, the CAG also flagged that 7,49,820 beneficiaries were linked with a single mobile number (9999999999) in the Beneficiary Identification System (BIS) database. Similarly, another mobile number (8888888888) is linked to 1,39,300 beneficiaries.
NHA, while agreeing with audit observations, stated that with the deployment of BIS 2.0, this issue should be resolved.
“Further, the BIS 2.0 system has been configured so that more than certain number of families cannot use the same mobile number. This shall arrest the prevalence of entering “random numbers” which constitute the overwhelming cases of mobile number inconsistency,” the NHA told CAG.
