Insurance company highlights implementation challenges
The Nagaland Health Protection Society (NHPS) has clarified that the Pradhan Mantri Jan Arogya Yojana (PM-JAY) and the Chief Minister Health Insurance Scheme (CMHIS) are fully operational across the state. This statement comes amidst concerns over reports of service suspensions by certain empanelled hospitals, which NHPS attributed to a miscommunication with the insurance provider, Future Generali India Insurance (FGI).
In a press release, NHPS reassured beneficiaries that the services under both schemes have not been interrupted. It warned that any unilateral suspension by hospitals would violate the terms of their Memorandum of Understanding (MoU). “All empanelled hospitals have been duly informed to continue offering cashless services to beneficiaries,” said Thavaseelan K, CEO of NHPS.
NHPS highlighted the financial performance of the schemes, noting that a total of Rs. 53.64 crores was disbursed for claims under PM-JAY and CMHIS (General) and Rs. 34.54 crores under CMHIS (Employees) in the fiscal year 2023-24. For the current fiscal year 2024-25, Rs. 38.92 crores and Rs. 33.52 crores, respectively, have already been paid.
Claims for treatments outside Nagaland totaled Rs. 3.99 crores under PM-JAY and Rs. 3.81 crores under CMHIS (Employees) last fiscal year. For FY 2024-25, Rs. 1.95 crores under PM-JAY and Rs. 10.16 crores under CMHIS (Employees) have been disbursed so far. The NHPS noted a 17% annual compounded growth rate in premium utilization, reflecting the schemes’ rising popularity.
Insurance company’s stand
Future Generali India Insurance Company (FGI) acknowledged challenges in implementing the AB PM-JAY CMHIS schemes in Nagaland and affirmed its commitment to resolving these issues.
“We have been working with the relevant authorities to address these challenges in the interest of sustainability and to ensure that customers are not at a loss. As lifetime partners to our customers, we remain firmly committed to serving all who are insured with us,” FGI stated.
The company emphasized the need for fraud control and sustainable premiums to avoid undue pressure on the state exchequer. “Any policy administrator or insurer would be forced to hike rates to reflect claims outgo. Besides the claims paid out, significant administrative costs are incurred. Finally, it’s the honest taxpayer who will bear the brunt of a system that fails to control leakages,” FGI added.
FGI assured that all claims for genuine cases would be honored while addressing concerns about unethical practices.
Concerns over fraud
NHPS disclosed reports of alleged fraud and misuse, including financial exploitation of vulnerable patients by certain empanelled hospitals, jeopardizing the schemes’ sustainability.
“The Department has initiated investigations to examine these allegations and ascertain whether any fraud or abuse has occurred. Strict action will be taken against hospitals found violating guidelines or statutory compliance,” NHPS stated.
Both PM-JAY and CMHIS schemes provide cashless services for beneficiaries at empanelled hospitals. “Beneficiaries are not required to make any upfront payment for treatments covered under the schemes unless the services fall outside the entitlements,” NHPS clarified.
Instead, treatment costs are directly settled between the empanelled hospitals and the insurance company. This system ensures that financial barriers do not prevent eligible households from accessing quality healthcare.
NHPS urged stakeholders, including hospitals, not to issue service suspension notices without prior confirmation from competent authorities, as such actions cause unnecessary public confusion.
For assistance, beneficiaries can contact the toll-free helpline at 1800-202-3380.