Medical insurance in India for the elderly - I

Health Scheme for the Central Government pensioners

(This is the first part of a multi-part post on this subject. This is not meant to be a comprehensive source of information on various insurance schemes for the aged in India as of now, but rather tries to offer somewhat of a critical appraisal from a user perspective cutting through the received wisdom and advertisement blurbs. The present one talks about one of the most important government funded schemes, a subsequent post will take a look at some of the other health insurance policies available in the market.)

A major escalation in the drug prices and the cost of an increasingly privatized health care in India that has occurred over the last two decades and the liberalized economic policies pursued by the government are significantly correlated, notwithstanding the expected murmurs of protests from the liberalization fetishists against this inference. There seems to be enough wisdom within the government (PMO/panning commission) and advice from outside propelling the government propelling it to get out of the welfare commitment to supply public health care as much as possible and allow private health care providers to take its place and let the market enjoy a free run. This is more than clear both by the various policy pronouncements and through experiences on the ground. Ample statistics exist in the public domain to demonstrate the ballooning of what has been rather graphically described as the OUT-OF-POCKET (OOP) expenditure for health (generally accepted to be about 70% of the total) for the majority of Indians. This is a significant and potentially disastrous burden especially for the poor and of course the elderly and may lead to penury and destitution. I have had occasions to discuss these issues in some of the earlier posts in seinjuti (see, “Drug prices escalation potential in India”, November 5, 2011, “OOP health expenses of India”, November 6, 2011) and more recently elsewhere (“Price of health”, silvertalkies, October 6, 2012).

In this connection, one has only to look at the dwindling utility and effectiveness of the Central Government Health Scheme (CGHS). This is one among the few relatively well-organized government sponsored schemes through which a modicum of medical insurance benefit is provided to the employees (and their dependents, total beneficiaries estimated to be about 4 million or so) working in various central government departments and offices all over the country and autonomous institutions like CSIR under the government of India. CGHS scheme and the rules governing it [under the broader Central Services (Medical Attendance) or the CS (MA) Act of 1954] cover both serving government employees and the pensioners. For the latter, since we are concerned here about the elderly, this service is usually available after retirement either by paying a sort of annual premium or (what is becoming the norm more recently) by making a one-time lump sum payment. In this sense this is like a usual medical insurance offered by private companies for the elderly.

Over the last several years, because of the deliberate reduction (as a government policy) in the CGHS approved rates for a large number of diagnostic tests and procedures (both taken as in-patients or in the OPD) and generally not accepting the market rates charged by good private hospitals, many of these are opting out of the CGHS scheme or are being de-recognized by the government. Even where the treatment in some of these hospitals are not completely disallowed, the CGHS insured has to agree to pay the difference between the rates charged by the hospital and those allowed under the CGHS schedule, even before the admission or undergoing a procedure. Hospital bills may also create such differentials due to the price differences between branded drugs sometimes prescribed by the hospitals and the equivalent generics allowed within the CGHS schedule. The same is true about some critical prosthetics (certain high end drug eluting coronary stents used in angioplasty are ruled out under the revised CGHS schedule). More often than not this may mean 40-80% in OOP. Alternatively the insured has to go and get treated at the restricted number of CGHS recognized hospitals where the test and the treatment facilities may not be up to the mark or one does not get to choose his/her preferred or recommended doctors (who are not necessarily associated with or may not choose to operate in these latter hospitals).

The service is operated either as a cash-less (or the direct payment) facility or as a reimbursable one. In the former the pensioner produces document authorizing the hospitalization and the treatment (office memo, letter from an authorized medical attendant, etc) acceptable to the hospital whereupon the treatment is provided without charging the CGHS beneficiary (except for the differential payments explained above that can be substantial in some cases and some hospitals). At the end of the treatment, the hospital sends bills, details of treatment and other documents to the concerned government office/authority for verifying and accepting the expenditure and finally sanctioning the payment as per its accounts office calculations. In case the office disagrees with some parts of the bill in the sense that these are not admissible under the current CGHS schedule these amounts are recovered from the pensioner.

Many elderly pensioners, especially those not having much human support system (relatives and friends) often find obtaining the correct authorization document from the CGHS dispensaries or the city headquarter time consuming and not devoid of harassment, especially as these offices are not always close to their residence or near the hospitals of interest.  

In the case of the reimbursable route, the pensioner makes the payment upfront to the hospital and submits the bills (including complete break up of all expenditure) and the supporting documents like test reports, prescriptions for medicines and tests   appending the same to the application to his/her accounts office. The latter after scrutiny and verification with the hospital, reimburse the expenditure, which could be much lower than the actual depending on the admissible rates of treatment, recognition level of the hospital where the treatments are taken. It may strain one’s credulity, but it is true that if a pensioner, because of his/her salary level at the time of retirement has the medical card branded, for instance, as “semi-private”, he or she would not just be entitled to a hospital accommodation in the semi-private ward or some other below that grade, entitlements for many of the critical treatment costs (including surgical or other procedure charges) are also graded in terms of admissible charges under the CGHS schedule. If one uses a higher than entitled accommodation for some unavoidable reasons or that the hospital does not allow for such gradations of charges and insist on levying standard charges the differences are not reimbursed and the pensioner has to make this payment. Thus it is not difficult to appreciate that despite availing of a government sponsored medical insurance the pensioner may end up incurring substantial OOP expenses.

Anecdotal evidence (based on the actual experiences of many pensioners) indicates that the claim settlement in the case of reimbursement often gets delayed by the cavalier attitude of the hospitals in providing incomplete documentation along with the final bills and completely rigid and often indifferent and non-cooperative handling of such deficiencies in the reimbursement applications by the government accounts offices. Though the pensioner is not really to blame, he/she must personally at his/her own cost get the required documents from the hospital billing department in order to expedite the reimbursement process.

The bright side of the CGHS scheme for the pensioners is that the OPD treatments and tests taken at and medicines prescribed by the designated CGHS dispensaries are practically free of cost (covered within the terms of the scheme). Similar tests and/or treatments can be availed at the recognized hospitals or by doctors from a CGHS empanelled list of the so-called “authorized medical attendant”s or the AMAs  generally at subsidized prices. Unfortunately, however, such dispensaries and AMAs are comparatively few in number and concentrated more in the main cities (about 25 or so) considering the countrywide validity of the scheme.

The number of recognized (empanelled) hospitals is coming down by the year. Many of these being government hospitals, which have to cater to the disproportionately large number of patients especially the poor and those from the lower strata of the population, are ill equipped, lack sufficient facilities, cleanliness and hygiene, important medicines, blood products and sometimes even good doctors. Many pensioners wishing to avail the scheme perforce have to choose to go to these hospitals.

Why secularism and freedom of expression have India specific connotation

The democratic experience in India is, comparatively speaking, shallow. We have been introduced to democracy rather late, around the middle of the last century, our political structure based on a borrowed template and formally modeled more or less on the British practice. India was not a democratic country before the colonial take over by the British or even during the major part of their rule, if one leaves out the last twenty odd years. During this latter period some rudimentary democratic institutions came into being as ad hoc response from the rulers to meet the increasing self-rule demand from the articulate educated Indians belonging to some strands of the nationalist movement. These were by no means expressions of mass democracy.

Anti-British movement led by Gandhi and others in Indian National Congress was primarily a political agitation by the Indian masses geared principally to remove the colonial yoke and aimed at major changes in the political superstructure characterizing the country (or the major parts of the country). To the participants of the freedom movement and the people at large the facile assumption was proffered by the leaders that the ‘freedom’ from the colonial rule will necessarily mean democracy, especially as it was being sought to be safeguarded by a meticulously worked document like the ‘Constitution’ (some very erudite, brilliant and humane Indians of the time having authored it). And with the first countrywide general election based on universal suffrage a significant measure of democratic practice was also demonstrated on the ground.

Despite many apparent failures and limitations of and attempts at subversion on our democracy it has to be ungrudgingly accepted, however, that this aspect of our democratic freedom – the ability of the Indians across the length and the breadth of the country to more or less freely exercise their electoral choices at periodic intervals – has remained sacrosanct for all these sixty five years. Being able to throw out of office through a largely non-violent election process the particularly hated dispensation of Emergency introduced by the Congress party during mid-1970s, or the unusually long (for about 34 years) self-perpetuating mis-governance by the left front in West Bengal that almost appeared as a fait accompli bear testimony to the strength of the functioning though flawed democracy in India. In view of what had happened in terms of the shrinkage of the democratic space in many countries in India’s neighborhood and elsewhere, countries that won freedom from the colonial rule around the same time as India this is rightly considered by many as a significant achievement.

Within this basic and broad democratic framework our polity through its varied and evolving strands (roughly represented by various political parties and groups) has managed to develop its programmes projected to benefit the majority of the people and organize corresponding actions so as to best serve the cause laid down by these programmes. The latter could be addressing planning and executing economic development projects, scientific management of the natural resources, managing country’s finances, creating and organizing infrastructure for health and education for the burgeoning population, engineering social upliftment and promoting social mobility, maintaining peace and harmony among a large and widely heterogeneous population characterized by diverse ethnicity, religion, caste, language, economic conditions, etc.

It is in this context that quite early in our experiment with democracy in the post-independence India (in about twenty years or so), the Congress party which by virtue of the momentum it carried from leading the freedom movement had taken over the governance of almost whole of India, lost the absolute monopoly in deciding the form, the content and the priorities of these programmes and who the beneficiaries of these would be. Partly because of conceptual inadequacy in understanding and mediating democratic reforms in a poor, underdeveloped, predominantly agricultural country with effectively feudal land relations and partly out of plain incompetence, arrogance of power, greed and corruption, the ruling party quickly lost the moral hegemony to lord over such a vast and diverse land. Soon there were other claimants to the mantle. First they came flaunting contrasting ideological worldviews. But gradually the challengers put up the flagstaff of diverse identities – of castes, religions, regional and tribal aspirations for ‘self-determination’ - appearing to shoot their arms and articulate newfound voices through the imposed veil of suzerainty of a central government with an overarching national ethos and perspective.

Since then it has become an open season for competition for occupying the preeminent place within the political space among all manner of opportunistic coalitions of groups openly and avowedly promoting their sectional interests and agendas that could sometimes appear almost irreconcilable to each other, quite apart from working against the demands of a modern nation in the 21^st century world. An important aspect of freedom interpreted within democratic India is thus an almost infinite tolerance of the articulation of a restricted, sectional identity even if that works at cross purposes with the interest of ‘others’ (beyond the given group or section) and the ‘nation’ as a whole, if that matters any more to the promoters of identity politics in India.

This incidentally seems to be consistent with the common interpretation of secularism as defined in our constitution. Within the scope of this interpretation, the Indian state (governments both at the center and in the states) can not just be neutral about all religions, they will have to actually bend over backwards to publicly support disparate agendas of followers of each religion, which effectively translates to supporting the religious organizations, parties and those ambitious elites leading them. Religion in India is not something of a cultural value system or worldview practiced by individual followers in private, without demonstrably occupying public space or grabbing public attention or demanding expenditure of public money (or the state’s indulgence or munificence in any way).

That is why shifting or demolishing (even under court order) temples or mosques whether these are of older or recent origins on busy public roads causing clear inconvenience to the flow of traffic in a modern Indian city can be an emotive and law and order issue. In the same vein the financial support by the government for the Haj pilgrimage is expected to be a time honored and therefore compulsory gesture that no decent government hoping not to antagonize a religious group can withdraw. Nor can the government afford to show itself to be fatally insensitive by proposing to control the noise levels in the residential areas and townships in modern cities and towns contributed by the quotidian calls to the faithful and blaring of religious sermons and functions over loudspeakers. And to speak of being wary of regimentation and proliferation of very archaic, ultraconservative ideas and mores among the co-believers in such congregations will be construed as sacrilegious.

That is why a literary work like fiction, essay or a poem or a work of art like painting, a cartoon or a film or play in contemporary India can and does routinely run afoul with the sensitivities of the one or the other among the myriad affiliates of religious allegiances. And the secular government respecting the fundamental rights (to preach and practice a religion) of the aggrieved, enshrined under constitution, is expected to assuage the hurt feelings (due to a perceived affront) by promptly stopping a painting exhibition, live performance or a theatre show, denying censorship certificate to a movie and banning the publication and sale of a book. In addition, most often by an unwritten convention, the state has to remain a passive spectator of the active vandalism and destruction of properties by the mortified activists exercising their freedom in dispensing vigilante justice on the perceived infringement of ‘their’ fundamental rights. Curiously, though, the minor matter about protecting the freedom of expression of the artists and writers and filmmakers under the same article of the constitution never arrests the attention of the government.  

It is true that religion happens to be a common enough trigger for backlash on the freedom of expression. However, freedom to preach and practice rabid regionalism, ethno-linguistic chauvinism, to promote caste-based reservation in jobs and promotion, to demand self-determination for a dwindling tribal identity are all very sacrosanct in India. And every Indian worth his salt should clearly know that his freedom to express any rational view on any of these matters is naturally secondary to the primary freedom of a host of other Indians of sensing a hurt in their identity and ideology.   

Interestingly, recent experiences also show that the way governments – both at the center and in the states – respond to an alleged infringement of freedom of belief (in a religion, a cultural practice, a certain ideology etc.) is highly variable. A leader of a political outfit can employ a language in his speech what, for all practical purposes, appears extremely abusive to an average Indian audience in describing or interpreting an action of a political opponent or a group, generally without inviting a rap from the law enforcing authorities.  In the cases of clear hate speech by some politicians against the believers of a rival religion the police have to be literally coaxed and pressured by the superior courts and mounting public opinion to even initiate some tardy actions. But when an anonymous netizen draws a cartoon of a politician and another shares the same over the cyberspace or a non-political challenger like Anna Hazare or Arvind Kejriwal (in the days before the Aam Aadmi Party was born) or Kiran Bedi lampoons a politician these would galvanize privilege motions in the parliament or immediate police actions by cyber-sleuths and arrests (preferably without bail) under tough provisions of the Information Technology Act. When a movie situates a budding terrorist in an in-your-face realistic cultural, religious and social setting, the filmmaker is hauled over coals for religious stereotyping of terrorism and movie theatres vandalized in whipped up public freenzy.     

Thus it is not always important as to what is being said, but rather who is saying that. Freedom is enshrined for a privileged section of the Indians to take offence on the slightest pretext and hurt others by word or action with impunity, but it will be jail for other lesser mortals in the country who dare emulate similar behavior or aspire for the same privileges.