Times of India
02 September 2010
By Pervez Iqbal Siddiqui
Lucknow, India

Fictitious Claims Under Government Health Insurance Scheme For BPL Exposed
Doctors in Uttar Pradesh have a solution for everything, it seems. So, when the son refuses a surgery for his hernia, his father can get it done. It doesn’t matter if he does not need the surgery. Everybody goes home happy, with a few thousand rupees tucked in the wallet.

The national health insurance scheme (NHIS) has apparently come as a boon for the state’s doctors and, of course, for the intended beneficiaries from the below poverty line (BPL). A government insurance cover for BPL card holders, NHIS covers any five members of a BPL family for a cashless medical treatment up to Rs 30,000 per year at listed government hospitals and private nursing homes. However, ever since the scheme was launched in July 2010, scores of claims were verified to be fictitious.

Like the rickshaw puller’s case who was operated upon for hernia. Ram Kishun – a rickshaw–puller from Mau Bazaar locality in Chitrakoot – has accused the doctors of a private nursing home of making him undergo a surgery for hernia that his son was suffering from. In his written complaint submitted to the deputy inspector general (DIG) Allahabad, Ram Kishun had accused the hospital of making him undergo the surgery to claim under the NHIS. Director of the nursing home, Dr Sharad Sahu had, however, claimed that after his son refused to undergo surgery, Ram Kishun volunteered himself and the subsequent claim has been sought on his smart card only.

In another instance, also from Allahabad, the rural development commissioner office lodged a case against one Rama Hospital. Allegations were that they admitted an unusually high number of patients who underwent a surprisingly identical line of treatment. The case was lodged after district magistrate (DM) Allahabad, found the allegations as prima–facie true in a preliminary inquiry ordered by him. The findings confirmed that the intention behind the move was to provide monetary benefits to patients and the hospital through illegal recourse.

Earlier, in an interesting case from Kanpur, one Shakuntala (60) of Balha Para Kalan village in Patara block and that of Meru Lal (72) of Pankha Bahadur Nagar locality of Kalyanpur block were treated at Rajaram Hospital in Panki. The claims for their treatment were submitted for reimbursement by the hospital. According to additional chief medical officer (ACMO) Kanpur, Dr Rajesh Jha, the documents show that Shakuntala underwent a surgery for hydrosil while Meru Lal’s foetus was removed.

Manager of the hospital Dewakar M, said that it was a mistake on the part of the person issuing the smart card who interchanged the photographs of the two cards. Not withstanding any such claim, the hospital in question has been delisted from the panel of NHIS.

Given the experience with government agencies and the scale of operations under the scheme, this appears to be just the tip of the iceberg. In the first round of its launching, over 80,000 BPL card holders from 15 districts of Uttar Pradesh got the smart card with a choice of seeking treatment from 134 hospitals listed for the purpose in the region.

By July end, claims worth Rs 32.49 crore were received out of which Rs 31.14 crore were reimbursed. In the second round, 59 districts of the state were covered which offered these services at 150 government and 815 private hospitals. As per the government statistics, 1.5 lakh patients have benefited from the scheme till date.