Insurance Without Assurance

Complaints such as “insurance claims by hospitals have not been reimbursed,” “medicines were unavailable despite insurance coverage,” and “claims were rejected” are becoming increasingly common under the national health insurance programme. Originally launched to make healthcare accessible and affordable for all, the scheme now appears to be struggling for its own survival. Widespread dissatisfaction among beneficiaries, hospitals, and government authorities alike highlights deep structural flaws within the system. The most alarming sign of the crisis is the suspension of insurance services by major public hospitals. Following the footsteps of Shahid Gangalal National Heart Centre, the country’s premier TU Teaching Hospital in Maharajgunj has also halted services under the scheme. Hospital authorities cite delayed reimbursements and a rising number of rejected claims as reasons for the decision. The continued uncertainty over when—or whether—these services will resume is deeply concerning, as it has effectively denied insured citizens access to treatment. Officials at the Health Insurance Board acknowledge weaknesses at both the policy and implementation levels. Introducing health insurance within the broader social security framework, setting a uniform premium instead of adopting a progressive contribution model, and failing to define clear ceilings and standards for treatment costs have all weakened the insurance fund. Unnecessary diagnostic tests, inflated or superfluous services, and the practice of not renewing insurance after receiving expensive treatment have further strained the system financially.