The Nagaland Health Protection Society (NHPS) has intervened in a case involving a Chief Minister Health Insurance Scheme (Employees & Pensioners) (CMHIS (EP)) beneficiary who was billed an additional Rs 5.15 lakh during a prolonged Neonatal Intensive Care Unit (NICU) admission, reiterating that empanelled hospitals must provide cashless treatment in accordance with the Scheme Guidelines.
According to the NHPS, the beneficiary raised a grievance after the empanelled hospital billed Rs 5,15,704 for the course of treatment, while only Rs 1,63,975 was processed and settled under the scheme as the eligible claim amount.
Following the complaint, the NHPS said it had taken up the matter with the concerned hospital and reminded it of its obligations under the CMHIS Scheme and the Memorandum of Understanding signed at the time of empanelment.
The Society clarified that NICU bed charges, newborn care packages, oxygen support, laboratory investigations and diagnostic services are covered under approved package rates,…
…while medicines are reimbursable through the Scheme’s open billing mechanism in accordance with the National Pharmaceutical Pricing Authority ceiling rates or the actual cost of the medicines.
It further stated that consultation charges are already included in the approved package rates and can be claimed separately only in cases of approved cross-consultations as provided under the Scheme Guidelines.
Reiterating the cashless nature of the scheme, NHPS said empanelled hospitals are not permitted to recover any additional amount from beneficiaries except for non-payable items specified under the Insurance Regulatory and Development Authority of India (IRDAI) guidelines, such as diapers and toiletries, or where beneficiaries voluntarily opt for higher room categories or implants beyond their entitlement.
The Society also stressed that all available package provisions and claim settlement mechanisms under the CMHIS must be fully utilised before concluding that any expenditure falls outside the Scheme’s coverage.
Accordingly, the concerned hospital has been advised to process the claim strictly in accordance with the applicable CMHIS package provisions and Scheme Guidelines and to refrain from recovering any amount from the beneficiary except in circumstances expressly permitted under the Scheme.
The NHPS said it remains committed to protecting the interests of beneficiaries and ensuring that all empanelled healthcare providers comply with the Scheme Guidelines. It also urged beneficiaries and empanelled hospitals to contact the NHPS at the earliest in case of any difficulty to facilitate timely resolution of grievances.
Beneficiaries of AB PM-JAY and CMHIS may seek assistance or register grievances through the NHPS toll-free helpline at 1800-202-3380, available via both call and WhatsApp.
