Nagaland Health Protection Society (ABPM-JAY CMHIS) DH&FW informs

The Nagaland Health Protection Society (NHPS), under the Department of Health & Family Welfare, Government of Nagaland would like to inform the general public and stakeholders regarding the continuing delay in health insurance claim settlements under the Chief Minister Health Insurance Scheme (CMHIS) and Ayushman Bharat Pradhan Mantri – Jan Arogya Yojana(ABPM-JAY) by Future Generali India Insurance Co. Ltd. (FGI).

Since its launch, CMHIS and AB PM-JAY have provided equitable access to quality healthcare services for the people of Nagaland. However, the prolonged delay in settling legitimate claims by FGI has created growing operational and financial challenges for empanelled hospitals, impacting beneficiaries.

Key Facts and Actions Taken:
1. Outstanding Claims Status (as of 14thApril 2025):
Total Claims Submitted: Rs 178.96 Crores
Total Claims Approvedby FGI: Rs 147.65 Crores
Total Claims Paid by FGI: Rs 99.28 Crores
Total Claims Pending (Under Process/Approved but Payment Pending): Rs 48.81 Crores
Total Claims Rejected by FGI: Rs 8.40Crores

In December 2024, FGI raised concerns regarding suspected fraudulent claims involving some hospitals, submitting what it referred to as “fraud dossiers”. NHPS took immediate cognizance of the matter and independently verified the records through its internal audit teams and district authorities. The findings revealed that:

1. A majority of the claims flagged as fraudulent were either genuine or already under investigation by NHPS.
2. The insurer failed to substantiate most of the allegations with adequate documentary proof.
3. NHPS had, in good faith, extended full cooperation and offered a joint verification mechanism to which the insurer has remained unresponsive.

FGI has currently withheld further claim payments, citing alleged frauds by empanelled hospitals. This action is in contravention of the contract provisions and the National Health Authority’s (NHA) Guidelines for Recoveries and other Actions Post Confirmation of Fraud and other Irregularities, as the alleged fraud cases have not yet been proven beyond reasonable doubt. This delay is further exacerbated by FGI’s lack of co-operation, despite earlier mutual agreement to resolve such cases through joint physical audits.

Despite repeated assurances from the State Government to fully co-operate in recovering payments related to fraudulent claims and to support punitive actions wherever justified, and the commitment of the Nagaland Private Doctors’ Association (NPDA) to penalize erring hospitals, FGI has failed to respond to requests to process and release genuine claims without arbitrary rejections.

It is important to note that the State Government has paid the full premium due to FGI i.e. 91.99 Crores as per the contract agreement.

While NHPS remains committed to ensuring accountability and will not tolerate misuse of public resources, it also stands firm against the blanket withholding of claims by FGI that adversely affectspatients and empanelled hospitals. NHPS has already suspended the empanelment of two (2) hospitals for a period of 6 months and has initiated recovery from two (2) hospitals. This is an ongoing exercise and further recoveries will be made against claims that are proved to be fraudulent beyond doubt.

NHPS would further like to inform that the following actions are being taken to resolve the issue:
1. At the Government/Regulatory level:
The issue has been formally escalated to the –
1. Insurance Regulatory and Development Authority of India (IRDAI)
2. National Health Authority (NHA)
3. Department of Financial Services (DFS), Ministry of Finance, GoI

All relevant documents, including claim status have been shared with these agencies for regulatory intervention.

2. Contractual and Legal Recourse:
NHPS is actively examining available legal and contractual options to ensure adherence to the service agreement signed between NHPS and FGI. Deliberations are ongoing regarding appropriate penal and remedial actions.

3. Continuity of Services and Beneficiary Advisory:
As a stakeholder in the health care delivery in the State, NHPSwould like to make an earnest appeal to all the private EHCPs in Nagaland to continue with the services while the Department is undertaking all efforts to resolve the non-payment issue.

In the event that any empanelled private hospital within the State is not willing to provide cashless services under CMHIS and PM-JAY due to the ongoing impasse, beneficiaries are advised to visit any Government hospital, CIHSR Dimapur or any empanelled hospital outside the State. All Government hospitals, CIHSR Dimapur and empanelled hospitals outside the State will continue to provide uninterrupted and fully cashless treatment services under the scheme.

NHPS, on behalf of the Government of Nagaland, reaffirms its commitment to the people. Every effort is being made to restore normalcy in the claim disbursement process, hold the insurer accountable, and ensure that no eligible citizen is denied timely and quality healthcare under CMHIS / AB-PMJAY.

For further information, please contact the NHPS helpline 1800-202-3380.

(Source: DIPR)

MT