Morung Express News
Dimapur | December 27
A major private hospital in Dimapur put up a notice informing that it will be suspending the state-sponsored cashless treatment services. “Eden Medical Centre regrets to inform that we are compelled to suspend all services relating to Ayushman/PMJAY/CMHIS from 30th December 2024 till all the dues owed to the hospital are compensated in full,” read the undated notice.
The hospital management was not available for comment. However, Health department officials attributed the reason to outstanding insurance claims.
Sources in the Nagaland Health Protection Society (NHPS) told The Morung Express that the said hospital flagged the issue about a week back, before the Christmas break, about pending claims/payment from the insurance company. The amount due was not disclosed.
The NHPS is the nodal agency for administering public health protection schemes in the state, including Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB PM-JAY), Chief Minister’s Health Insurance Scheme (CMHIS), and other relevant health protection programmes.
The payment from the insurance company has allegedly been delayed for about a month now as opposed to the two-week deadline. Future Generali India Insurance is the insurance provider.
As per the sources, the contract with the insurance company states that all treatment claims under the CMHIS and AB PM-JAY have to be settled within two weeks. For every additional day after the deadline, the insurance company incurs penalty, implying it has to pay the pending amount plus the accumulated penalty to the empanelled hospital.
While stating that the NHPS has raised the issue with the insurance company, the sources revealed about a meeting between the NHPS and the company, which happened on December 19. At the meeting, the company claimed that it was incurring expenditure in excess of the prevailing premium due to alleged “over utilization” of the health insurance schemes in Nagaland.
The total premium, from the government to the contracted insurance company, comes to about Rs 93 cr per annum at present.
The company told the meeting that they have already overshot the premium for the 2024-25 fiscal. The payments by the company has reportedly crossed the 100 crore mark, as of December. “At this rate, they said that they may end up spending around Rs 130-140 cr by the end of the current fiscal,” said one NHPS source.
The current claims backlog due to the empanelled hospitals in the state was said to be about Rs 21 cr. The source further said that the insurance company hinted at hospitals colluding to make money out of the state sponsored health schemes. This aspect of the allegation was however not established, with the source stating, “We are trying to investigate.”
“We are not siding with any one party. We are looking into what the hospitals are doing, whether there are any instances of abuse or misuse. On the other side, also, we will ensure that the insurance company pays the claims to the hospitals (as per the contract),” the source added.
As rendered in the contract, the source said that the financial risk is with the insurance company even if the payments exceed the insured premium.
Other hospitals have also reportedly flagged delays in settling treatment claims. Asked how the issue will be settled, the source said, “That is what we are trying to. We are in talks…”
