Highlighting the design and implementation flaws in the ‘Pradhan Mantri Garib Kalyan Insurance Scheme for Health Workers fighting COVID-19 in Government Hospitals and Health Care Centres’, TANVI SINGH and ANUSHA R explain why it is necessary to urgently fix these gaps to ensure that all deserving health care workers, who are at the forefront of our pandemic response, can avail of the scheme.
ON 27th March 2020, a COVID relief package worth INR 1.7 lakh crore was introduced by the Union Finance Ministry. This included insurance cover for the approximately 22 lakh health workers of India. The package, known as the ‘Pradhan Mantri Garib Kalyan Insurance Scheme for Health Workers fighting COVID-19 in Government Hospitals and Health Care Centres’ (PMGK insurance scheme) expired in April 2021 and was subsequently extended for another year. This package is funded through the National Disaster Response Fund, operated by the Union Ministry of Health and Family Welfare, and provides insurance cover of INR 50 lakh for healthcare workers.
However, a major flaw in its design is that the PMGK insurance scheme only covers loss of life due to COVID and accidental death on account of COVID-related duty.
This excludes from its ambit a substantial amount of assistance that most health care personnel are in dire need of, that is, the medical expenses of the survivors of the disease.
The mortality rate of the disease is only 1.1% while India is officially reporting around 2,50,000 cases daily at present. This means that only a very minuscule number of people, and more specifically only the families of the deceased healthcare workers, will be benefited.
While affected personnel can avail free health care facilities at the COVID designated hospitals, we are all aware of the kind of practical difficulties one currently faces in accessing not just public but even private healthcare facilities.
These are times when access is constrained by the privilege of power that is further compounded by the gross inadequacy of the health care infrastructure. As a consequence, people are being forced to spend unimaginable sums of money to procure private healthcare facilities as well as medicines (largely only available in the black market).
Eligibility Criteria for PMGK Insurance Scheme
Any claimant whose claim is accepted gets an amount of INR 50 lakhs, which will be in addition to any other schemes or insurance for which the person may be eligible, as per FAQ No. 13 of the PMGK insurance scheme. There is no individual enrollment required for this scheme.
It includes two types of covers:
1. Loss of life due to COVID
2. Accidental death on account of COVID-related duty.
In both kinds of claims, apart from the claim form, documents such as identity proof, proof of relationship to the deceased and death certificate need to be submitted.
In case of loss of life due to COVID, the claimant also needs to submit a laboratory report that certifies that the deceased had tested Positive for COVID.
Additionally, a certificate by the employer needs to be submitted stating that the deceased was an employee and was deployed or drafted for care and may have come in direct contact with COVID patients.
For accidental death on account of COVID-related duty, the claimant also needs to submit a post mortem report, a certified copy of the first information report (FIR), and a certificate by either the healthcare institution, organisation, or office that the deceased was an employee of and suffered accidental loss of life on account of COVID-related duty at.
During our research regarding the implementation of the scheme, the following barriers were identified concerning procuring and processing of documents required for the settlement of claims:
COVID Positive Certificate: States refusing to conduct post-death tests could mean that families of health care workers may not be able to claim insurance. There is also a lack of clarity in the scheme on whether the World Health Organization’s ICD-10 (International Statistical Classification of Diseases and Related Health Problems) Code U07.2 deaths, that is, suspected/clinical/probable deaths, qualify as COVID deaths. This is compounded by the fact that states are themselves not recording these deaths as COVID deaths.
Certificate of proof from employer:Another critical problem is that the family of the deceased health care worker has to get a certificate from the institution/organization/office employing them, showing that they contracted the infection on COVID duty or died as a result of an accident while on COVID duty.
In practice, employers are refusing to issue such certificates unless the health care worker came in direct contact with a COVID positive case. Since states are flouting Indian Council of Medical Research guidelines for appropriate recording of COVID-19 related deaths in India, and not counting co-morbid and suspected/probable/clinical cases as COVID deaths, many health care workers are being wrongly deemed ineligible under this scheme.
Ambiguity over what amounts to “drafted” or “requisitioned” by the government for COVID duty: In a recent case involving an insurance claim under PMGK insurance scheme for the death of a homeopathy doctor named B.S. Surgade, the Bombay High Court gave a very confusing judgment that has great repercussions for the eligibility criteria under the PMGK insurance scheme.
Dr. Suragde was sent a notice by Navi Mumbai Municipal Corporation (NMMC) to keep his hospital/Dispensary open during the lockdown period. The notice clearly mentioned that such a direction was issued under the Epidemic Diseases Act, 1897 for the “prevention and containment of COVID”.
The notice issued by NMMC also stated that if the clinic did not remain open, they would file an FIR against Dr. Suragde under section 188 of the Indian Penal Code, 1860. This clearly indicates that the intent and object of the NMMC notice was to order medical practitioners to keep their dispensaries open and ensure that citizens are given medical attention, including treatment for COVID.
However, the Bombay High Court concluded that there is no proof to aver that Dr. Surgade’s services were in fact requisitioned/ drafted in relation to COVID duties by the State. The court noted that there was a difference between specifically requisitioning or drafting services and directing private practitioners to not keep their clinic closed, and it was only the former that attracted the applicability of the scheme.
Simply put, this amounts to coercing private doctors to put their life in danger without providing them the same benefits as government doctors under the garb of restrictively-interpreted legalese.
Stagnation of Applications:In a letter sent to the union government in April, the Indian Medical Association (IMA) had raised concerns that insurance claims are getting stalled after they reach the Joint Directorates of districts.
As of 19th April 2021, out of the 756 modern medicine doctors (as per official records) who had sacrificed their lives to COVID, only 168 could receive this benefit, as per the IMA letter.
A total of 287 health care professionals have received this benefit till now. This data is not inclusive of Ayurveda and other alternative medicine practitioners who have also been mandated to render healthcare services in the pandemic.
A major hurdle faced by affected claimants is the procedural challenges in getting legal heir certificates, cause of death certificates, certificates of authenticity to prove they have worked in COVID health care, and so on at a time when the functional capacity of most administrative offices has been significantly reduced.
Verification of Claims:The Central Bureau of Health Intelligence (CBHI) has taken up the responsibility to trace and verify the list of health workers who are covered under the PMGK insurance scheme. The IMA is appealing to authorize all the people verified by CBHI to directly receive the benefit under the scheme as doing otherwise delays the already long drawn claim process, and also increases the chances of rejection of claims.
As per the government’s official announcement last year, this scheme was intended to benefit 22 lakh, health workers. As of 19th April 2021, 287 health care professionals, which is only 0.013% of the target number, have received benefits under the PMGK insurance scheme. This serves to highlight the failure in the design and implementation of this scheme.