Despite 5L govt cover, heart patient relies on charity for op

Time of India

03-05-2025

Mumbai: Riddled for a decade with a heart ailment described by doctors as a "poor man's burden", 24-year-old Rinki Sudhar finally got treated at civic-run
Sion Hospital
last week. The
rheumatic heart disease
(RHD) she contracted at age 13 had constricted her mitral heart valve, leading to persistent cough, sleeplessness and breathlessness.
Multiple misdiagnoses meant the UP resident had visited multiple hospitals across India, but the disease stayed true to its moniker. Despite her family being insured for Rs 5 lakh per year under the Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana (PMJAY), she needed charity for the procedure. Doctors led by cardiologist Dr Milind Phadke at Sion Hospital arranged for Rs 50,000 through a donor for a balloon mitral valvuloplasty (BMV).
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Public hospitals don't charge surgeon's fees or levy room charges, but patients require to pay for medical devices or instruments. This is where public insurance schemes like the state's Mahatma Phule Jan Arogya Yojana (MPJAY) or PMJAY come in. But Rinki was only eligible for the latter as she was not a Maharashtra resident.
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Insurance Gaps
Sudhar's case highlights the gaps and inadequacies in India's public health insurance schemes. According to PMJAY documents, the reimbursement for BMV was Rs 27,500 in 2020 and increased to Rs 35,700 recently. However, Sion Hospital's latest internal records show reimbursement of up to Rs 27,500 under PMJAY; in practice, only Rs 20,000 is allowed.
The cost of the balloon catheter alone is Rs 50,000, but even the state scheme (MPJAY) didn't cover BMV completely until last year. "When Rinki's case came up, there was a kind donor who wished to fund complete treatment of a cardiac patient. All the costs were taken care of by them, and that saved her life," said Dr Phadke, who operated on Sudhar.
Poor Man's Burden
RHD is rooted in deprivation. It begins with a sore throat caused by an untreated streptococcus infection, which can trigger an immune response that damages the mitral heart valve over time.
Rinki's father Ram (57), a watchman at an Andheri housing society, said her condition was often misdiagnosed. "Some doctors told us she had TB, some gave her vitamin injections," said Ram, who hails from Amethi. Dr Pratap Nathani, head of the cardiology department at Sion Hospital, said, "Factors such as malnutrition, lack of early access to diagnosis and treatment contribute to RHD."
Although Rinki's condition became unbearable in the past six months, it was only last month that RHD was diagnosed through a 2D-echo scan at a hospital in Sultanpur. She was referred to a govt hospital in Kanpur. "There was a long wait list, so we were sent to Lucknow," said Ram. In the meantime, they got their Ayushman Bharat card, and rushed to Mumbai. A resident at the building he works at helped him with Sion Hospital.
Recurring Troubles
State-run JJ Hospital, Byculla, treated around 200 RHD patients last year. "Most were covered by MJPJAY," said a cardiologist, adding problems arose when a patient was from outside Maharashtra. "We struggle with PMJAY as we need to approach trusts and donors to cover costs." A cardiologist from Parel's civic-run KEM Hospital said they used cross-subsidisation. "For some patients, the insurance amount is more than enough, so we use the excess amount to fund the deficit in another patient's coverage."
A former CEO of National Health Authority, which implements PMJAY, said, "There is a well-established mechanism in NHA to fix the rates. NHA doesn't fix the rates unilaterally and state considerations are taken into account.''
MJPJAY CEO Aannasaheb Chavan said there were similar issues at state-level, but most have been resolved since the state and union schemes merged. "We are also in the process of reviewing rates in the combined scheme,'" he said. A committee, headed by public health department head Amgothu Sri Ranga Naik, has been set up.
Dr Soumitra Ghosh from TISS's Centre for Health Policy, Planning and Management said, "It's common for patients under PMJAY to incur hefty out-of-pocket expenditures.'' Although PMJAY budget increased over the years, its beneficiaries too increased. "But the rates for specific procedures didn't increase accordingly," he said, adding, "Some health economists estimate that if the scheme truly offers coverage of Rs 5 lakh per family as promised, then the entire health budget would need to be allocated to it in order to keep it functional without any issues. Since that is not the amount of money currently allocated, the actual coverage cost is much lower than what is promised."
Not the End
Rinki, who is still in hospital, said she can now sleep without coughing. "I will look for a job, hopefully as a worker in a school," she said. But her cycle of deprivation has far from ended: The new valve will hold for at least 10 years before the narrowing restarts.