Vasant Davkhare

The health ministry of the state has decided to change the Third Party Administrator (TPA) in the Rajeev Gandhi Jeevandayee Arogya Yojana (RGJAY) after The Asian Age exposed corruption of Rs 500 crore in implementation of the scheme. Taking serious cognisance of the Age story, Dr Deepak Sawant, health minister, reviewed the scheme’s implementation and the amount spent on it.

Dr Sawant agreed that the commission of the TPA that was given to implement the scheme was 20 per cent and it was very huge. “The state government has not appointed the TPA. It was the responsibility of the insurance company to appoint the TPA to handle cases and administrative work at the hospital level,” said Dr Sawant.

He said, “We have taken serious cognisance of complaints about the TPA and have decided to change it by the end of November this year.”

The term of insurance companies that are providing services under the RGJAY is over, but the state government has extended it till September. The state will call a new tender for the next three years.

Elaborating on how the TPA received its commission, Mr Sawant said, “The state government has paid a premium of Rs 2,350 crore since the inception of the scheme. Every year, the state pays around Rs 700 crore to Rs 750 crore as the scheme’s premium. The TPA has received Rs 470 crore as commission, according to the 20 per cent rate mentioned in the agreement.”

Dr Sawant said that Rs 1,880 crore has been disbursed against the claims of patients; claims worth Rs 1,632 crore have been settled but not yet disbursed and Rs 241 crore has remained in the RGJAY society’s account.

According to the minister, claims worth Rs 85.89 crore are being processed, claims worth Rs 35.78 crore are pending at the hospital level, claims worth Rs 96.41 crore have not been submitted by the hospital to the insurance company and claims worth Rs 65.48 crore have been rejected.

The hospitals that have misused the scheme or cheated patients have been banned and removed from the empanelled list. “There are 15 hospitals, including Balaji from Byculla and Cure It from Nagpur, which were removed from empanelled list,” he said.

The state has kept a cap of 470 hospitals that will be empanelled under the scheme, but it will be removed in the new scheme. Also, the criteria of having 50 minimum beds will be reduced and hospital with 30 beds can participate in the scheme, Dr Sawant said.

At present 971 procedures and operations are available under the scheme.