Nagaland Health Protection Society says Future Generali India’s allegations of fraud cause delays in claim settlements

• DIMAPUR — The Nagaland Health Protection Society (NHPS) is reported to be grappling with significant delays in health insurance claim settlements under Chief Minister Health Insurance Scheme (CMHIS) and Ayushman Bharat Pradhan Mantri-Jan Arogya Yojana (ABPM-JAY) as a result of certain actions set in motion by Future Generali India (FGI) Insurance Co. Ltd.
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• In a statement issued on Wednesday, the society stated that the FGI has withheld payments citing alleged fraud by empanelled hospitals, a move that contradicts contractual provisions and national guidelines.
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• This has created financial strain for hospitals and is impacting beneficiaries' access to timely healthcare, it stated.
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• According to a set of ‘key facts and actions taken’ provided by the NHPS, as of April 14, a total of INR 48.81 crore in claims remain pending, either under process or approved but awaiting payment.

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• While the FGI approved INR 147.65 crore of the INR 178.96 crore submitted, only INR 99.28 crore has been paid.
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• The dispute began in December 2024 when the FGI raised concerns about suspected fraudulent claims “involving some hospitals submitting what it referred to as ‘fraud dossiers’.”
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• “NHPS took immediate cognisance of the matter and independently verified the records through its internal audit teams and district authorities. The findings revealed that a majority of the claims flagged as fraudulent were either genuine or already under investigation by NHPS; the insurer failed to substantiate most of the allegations with adequate documentary proof; and NHPS had, in good faith, extended full cooperation and offered a joint verification mechanism to which the insurer has remained unresponsive,” it stated.
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• Despite the state government's commitment to cooperate in recovering fraudulent payments and the NPDA's pledge to penalise erring hospitals, the FGI has reportedly failed to process genuine claims, it added.
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• “It is important to note that the state government has paid the full premium due to FGI, i.e., INR 91.99 crore, as per the contract agreement,” it stated.
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• According to the NHPS, it has already suspended the empanelment of two hospitals for a period of six months and has initiated recovery from two hospitals. “This is an ongoing exercise, and further recoveries will be made against claims that are proved to be fraudulent beyond doubt.”
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• In order to resolve the issue, the society claimed that it has taken various actions like escalating the issue to the Insurance Regulatory and Development Authority of India, the National Health Authority (NHA), and the Department of Financial Services, Union Ministry of Finance; exploring legal and contractual options to ensure adherence to the service agreement; and appealing to private empanelled hospitals to continue providing services.
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• “In the event that any empanelled private hospital within the state is not willing to provide cashless services under CMHIS and PM-JAY due to the ongoing impasse, beneficiaries are advised to visit any government hospital, CIHSR Dimapur, or any empanelled hospital outside the state. All government hospitals, CIHSR Dimapur, and empanelled hospitals outside the state will continue to provide uninterrupted and fully cashless treatment services under the scheme, it stated.
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• For further information, citizens can contact the NHPS helpline at 1800-202-3380.