Background: The NHPM is a central initiative targeting approximately 50 Cr deprived population of the country. When beneficiaries seek service from the providers, there is a chance for the raise of grievances. Whenever, a beneficiary faces any difficulty, it needs to be redressed through a dedicated system which is specially placed for this function, but efficient system will never wait for the grievances to arise but prevents it either at the stage of policy designing or implementation phase. Due to this reason, there is a need to study each clause of the policy document, and to know how it works during utilization by the policyholders.
Objective: To identify the clauses in the ‘Model Tender Document.volume.2 for Selection of Implementation Support Agency for providing support services for the implementation of AB-NHPM’ which could be of concern to the stakeholders of the scheme?
Methods: Secondary data analysis of newspapers, previous studies, and IRDAI’s regulatory documents for literature review. Results were obtained through review of ‘Model Tender Document.volume.2 for Selection of Implementation Support Agency for providing support services for the implementation of AB-NHPM’.
Observations: The clauses related to pre-existing conditions, exclusions, emergency conditions and Community Health Centre (CHC) hospitals could be of concern to the stakeholders in the scheme and affect overall quality of the scheme.
Conclusion: Firstly, although pre-existing diseases are covered, mostly people with chronic diseases require Out Patient Department (OPD) consultation, but OPD is excluded under this Scheme. Secondly, the clauses related to exclusions require clarification whether diseases related to alcohol, drugs and tobacco will be entertained or not because insurance companies are reluctant to cover. Thirdly, a few conditions related to emergency should be relaxed to the private hospitals in order to improve accessibility. Lastly, the CHCs hospitals will face difficulty in maintenance of MIS, resultant there could be problems with medical audit under the scheme.