KOHIMA — As
several empanelled hospitals suspended services under PM-JAY and CMHIS, the CEO
of Nagaland Health Protection Society (NHPS), Thavaseelan K has informed that
the department has initiated an investigation into allegations of fraud and
exploitation of vulnerable patients by certain empanelled hospitals.
After a meeting on Friday, the NHPS under the Department of
Health and Family Welfare issued a clarification announcing the continuation of
services under PM-JAY and CMHIS.
It clarified that the public services under the Pradhan
Mantri Jan Yojana (PM-JAY) and the Chief Minister Health Insurance Scheme
(CMHIS) are fully operational and have not been suspended.
“There was a miscommunication from the insurance company
(FGI) that has now been resolved,” said Thavaseelan after the meeting.
He informed all the empanelled hospitals that these services
will continue without interruption and will remain active.
Any hospital unilaterally suspending the services will be in
violation of the signed Memorandum of Understanding, he added.
The official highlighted that INR 53.64 crore for claims
under PM-JAY and CMHIS (general) and INR 34.54 crore for claims under CMHIS
(EP) were paid to various empanelled hospitals during FY 2023-24.
For the current fiscal year, INR 38.92 crore for claims
under PM-JAY & CMHIS (general) and INR 33.52 crore under CMHIS (EP) have
already been disbursed within Nagaland, he said.
According to him, claims paid for treatment availed outside
Nagaland amounted to INR 3.99 crore under PM-JAY and INR 3.81 crore under CMHIS
(EP) in FY 2023-24. For this fiscal year, the amount so far is INR 1.95 crore
under PM-JAY and INR 10.16 crore under CMHIS (EP).
Thavaseelan informed that the utilisation of premiums is
growing annually at a compounded rate of 17%, reflecting the increasing
popularity of these schemes.
"However, there have been reports of alleged fraud and
abuse/misuse, including financial exploitation of vulnerable patients by
certain empanelled hospitals. Such practices jeopardise the sustainability of
these schemes,” he said.
Accordingly, the department has initiated an investigation
to examine all such allegations and ascertain claims of fraud or abuse by
hospitals.
He warned that strict actions will be taken on any hospital
found violating guidelines or statutory compliance. “In the meantime, the
incumbent insurance company (FGI) is committed to releasing the claims amount
of genuine cases,” he informed.
As both PM-JAY and CMHIS provide cashless services, he
reminded that the beneficiaries are not required to make any upfront payment
for treatment covered under the schemes unless the patients ask for services
not entitled.
Instead, the treatment cost is directly settled between the
empanelled hospital and the insurance company to ensure that financial barriers
do not prevent eligible households from accessing quality healthcare
facilities, he explained.
Therefore, he urged the beneficiaries to verify the
eligibility and visit any empanelled hospital for cashless treatment.
Further, he asked all the stakeholders, including hospitals,
not to issue hasty notices regarding service suspension without confirmation
from the competent authority, “because such actions may cause unnecessary
confusion among the public.”
He also encouraged the public citizens to report any
unethical practices by hospitals to the state authorities.
An official from the Health Department also informed that
cashless service at CIHSR will continue, and Faith Hospital has also issued a
new notice on Friday stating: "Future Generali India Insurance Company has
communicated that cashless service under AB-PMJAY and CMHIS can resume.”
FGI clarification
Meanwhile, the Future Generali India (FGI) Insurance Company
issued an official statement on Friday stating that they are facing some
challenges in the implementation of health insurance under PM-JAY CMHIS in
Nagaland.
“We have been working with the relevant authorities to
address the same in the interest of the sustainability of the scheme and to
ensure that customers are not at a loss. As lifetime partners to our customers,
we remain firmly committed to serving all who have insured with us.
“The Nagaland state government too wants to control frauds
and ensure that the premiums are viable and don’t put pressure on the state
exchequer. Any policy administrator or insurer would be forced to hike rates to
reflect the claims outgo. Besides the claims paid out, there are significant
administrative costs too, which are incurred,” the statement read.
It pointed out that the taxpayers will bear the brunt if
leakages are not controlled.
