Numbers to hospitals empanelled: CAG flags breaches in TMC government insurance scheme

As per the CAG report, “The number of families enrolled under the Scheme (as of March 2023) was around 10 per cent higher than the number of families holding Ration Cards in the state, as per PDS records (of August 2023). Consequently, the risk of benefits of the scheme getting passed on to ineligible beneficiaries, in deviation (from) norms, could not be ruled out.”

While 2.43 crore families were enrolled for Swasthya Sathi as of March 2023 as per CAG, 2.21 crore held ration cards as of August 2023.

The number of beneficiaries under Swasthya Sathi had been gradually increased, initially covering only volunteers and other contractual workers and then expanding to universal coverage of all permanent residents of the state (except those covered by any other government health insurance / assurance scheme).

Apart from the discrepancy between the number of Swasthya Sathi and ration card beneficiaries, the CAG report says that while only one Swasthya Sathi card was to be issued per family, in the name of the eldest female member, the modalities followed in ensuring due compliance of this aspect remained unclear, with no documentation on record.

Auditors had done test checks in Birbhum, Hooghly, Purba Medinipur, Jalpaiguri, North 24 Parganas and Murshidabad districts, the CAG reports. Only in Jalpaiguri were the number of families enrolled for the health scheme less than those getting ration. Murshidabad had the highest gap, with the number of ration card holder families 16.85 lakh and Swasthya Sathi families 21.07 lakh as of January 2024.

The CAG report says that the nodal agency for Swasthya Sathi admitted the wide gap with ration card numbers “and stated this could be due to decadal growth rate and splitting of families”. “It also informed that mapping of all members through Aadhaar numbers was ongoing and the work of data sanitisation had been initiated & would be further strengthened to delete duplicate members from the SS (Swasthya Sathi) database. The reply of the government shows… (it) itself is not clear about the reasons behind the difference.”

It adds, “… there is an inherent risk that a family which is not a permanent resident of the state, is covered under some other health scheme… may also be in possession of more than one SS Card”.

One of the things it points to is that none of the 27 empanelled government super speciality hospitals under Swasthya Sathi were empanelled as Grade-A. “Owing to lower grading (and consequently lower package rates)… lesser amount (was paid) for treatments / medical procedures… thus impacting the revenue flow of these hospitals.”

The reverse, it says, is true of 31 hospitals which were “improperly allowed higher grading vis-à-vis available infrastructure, services being offered, sanctioned bed strength…”. “Due to improper gradation, these Health Care Providers, though entitled to lower package rates as per applicable norms of the SS Scheme, were being paid at higher rates.”

The CAG also talks of non-recovery of penalties from some partners for delayed settlement of claims, and “excess expenditure of Rs 46.97 crore on enrolment and distribution of smart cards to 1.65 crore families”.

With the Banerjee government having held out on Ayushman Bharat due to its insurance scheme, the CAG says this “deprived the state’s population, especially migrants… of the benefit of accessing cashless health care services in a network of hospitals across the country”.

Even the grievances regarding the scheme were not acknowledged, the CAG says. “No mechanism to track the redressal of grievances was available… No timeline and escalation mechanism had been prescribed for the settlement of grievances.”