Rs 5 lakh health cover for seniors under Ayushman Bharat: Who can avail

The announcement has sparked reactions across the healthcare and legal sectors. “Expanding health coverage to all senior citizens aged 70 and above under Ayushman Bharat PM-JAY, regardless of their socio-economic status, is a landmark decision in creating a more inclusive and fair healthcare system in India,” said Amit Chhabra, Chief Business Officer, General Insurance at Policybazaar.com. He added, “This move will fill a critical gap in India’s healthcare ecosystem, ensuring that senior citizens—who currently make up 10.5% of the country’s population—are not left without support during their most vulnerable years.”

Jasmine Damkewala, Senior Partner at Circle of Counsels and Advocate-on-Record, Supreme Court of India, said the initiative aligns with constitutional provisions. “This initiative is a commendable step towards universal health coverage, in line with Article 21 of the Indian Constitution, which guarantees the right to life and health,” she said.

Can all 70-year-olds benefit from this scheme?

The government has clarified that all senior citizens aged 70 and above, who belong to families already covered under AB PM-JAY, will be eligible for an additional top-up cover of Rs 5 lakh per year. This means families can share this coverage between their senior members.

Those benefiting from other public health insurance schemes, such as the Central Government Health Scheme (CGHS), Ex-Servicemen Contributory Health Scheme (ECHS), or Ayushman Central Armed Police Force (CAPF), may either stick to their current scheme or opt for the new AB PM-JAY benefits. Additionally, senior citizens under private health insurance policies or the Employees’ State Insurance Scheme will also be eligible for this expanded coverage.

How is coverage shared within families?

Health coverage for families with more than one eligible senior citizen will be divided. Ashwini Vaishnaw explained, “If there are two senior citizens (70 years+) in a family, then the Rs 5 lakh coverage will be shared between them. This is a big step towards ensuring the social security of senior citizens, especially as India transitions to nuclear families.”

Ageing India

Although the Ayushman Bharat scheme has been directed towards universal healthcare, this is the first time a specific age group has received comprehensive coverage. With India’s ageing population set to rise significantly in the coming decades, the need for accessible healthcare has become increasingly pressing.

India’s population over the age of 60 is predicted to rise from 8.6% in 2011 to 19.5% by 2050, according to the Longitudinal Ageing Study in India (LASI). In absolute terms, the number of people aged 60 and above will likely triple from 103 million in 2011 to 319 million by 2050. However, health coverage for this age group remains low, standing at around 20%, according to the India Ageing Report 2023.

Concerns remain

So far, the public has reportedly benefited by over Rs 1 trillion from the Ayushman Bharat healthcare initiative. However, despite the large-scale rollout, certain challenges remain.

One of the biggest issues raised is the limited participation of major private hospitals in the scheme. Many prominent hospitals, such as Fortis Healthcare, Kailash, Max, and Manipal Hospital, have yet to register for the Ayushman Bharat scheme. This raises questions about the scheme’s accessibility, especially for those who need advanced medical care. While many government and private hospitals are accepting Ayushman cards, the absence of these top-tier hospitals is being felt.

“The reported delays in payment to private hospitals raise concerns about the scheme’s implementation and may be in contravention of the provisions of the Clinical Establishments (Registration and Regulation) Act, 2010, which mandates timely payment for healthcare services,” said Damkewala. She suggested several measures to tackle this issue:

1. Ensuring timely release of funds to states and hospitals, as per the National Health Mission (NHM) guidelines.

2. Streamlining the payment process through robust IT infrastructure, in line with the Digital India initiative and the Information Technology Act, 2000.

3. Establishing an independent grievance redressal mechanism for hospitals, as provided for under the Consumer Protection Act, 2019.

4. Engaging with private hospitals to address their concerns and find collaborative solutions.

“By taking these steps, the government can ensure that the benefits of Ayushman Bharat reach the intended beneficiaries without any hindrances, and uphold the right to health enshrined under Article 21 of the Indian Constitution,” Damkewala added.

First Published: Sep 12 2024 | 5:20 PM IST