“Major misuse of premium funds in health insurance program”

Kathmandu. Minister for Health and Population, Dr. Sudha Sharma Gautam, has stated that there has been major misuse of premium funds in the health insurance program. She said that strict measures will be immediately implemented to stop this.

While making public the progress of her three-month tenure, she said it was found that unnecessary medical tests and treatments were being carried out with the intention of arbitrarily exhausting the annual limit of NPR 100,000 per family, and that service provider institutions were charging money with dishonest intent.

Minister Gautam said that financial imbalance is the main problem of the insurance program. According to her, challenges include claims exceeding premium collection, delays in payments, unnecessary consumption of services (moral hazard), higher participation of high-risk individuals (adverse selection), weak claims management, low participation from the organized sector, and lack of internal capacity within the board.

To address these problems, she said that the ministry and the Health Insurance Board jointly organized a national workshop and prepared an action plan based on 19 key action points. Minister Gautam also stressed that citizens must act responsibly in this regard.

She said, “People should not demand investigations just to exhaust the one lakh rupees. And service providers should also not carry out unnecessary investigations simply because they can charge up to one lakh rupees from a patient’s premium. Insurance cannot function that way.”

She further said, “In some cases, service recipients do not even know how much money has been spent from their premium, or whether someone else might be using services in their name, or whether claims have been made multiple times. Therefore, we have instructed the insurance system that from now on, as soon as a service is taken, an SMS notification should be sent informing the beneficiary how much money has been spent and how much balance remains. This arrangement is being made to prevent unauthorized individuals from using services in someone else’s name.”