The Nagaland Health Protection Society (NHPS), under the Department of Health & Family Welfare, has admitted that despite the Chief Minister Health Insurance Scheme (CMHIS) and Ayushman Bharat Pradhan Mantri – Jan Arogya Yojana (ABPM-JAY) providing equitable access to quality healthcare services for the people, prolonged delay in settling legitimate claims by Future General India Insurance Co Ltd (FGI) had created growing operational and financial challenges for empanelled hospitals, impacting beneficiaries.
The NHPS in a press release revealed that the total claims submitted stood at Rs 178.96 crore as of April 14, out of which FGI had approved claims amounting to Rs 147.65 crore, and Rs 99.28 crore had been paid, while Rs 48.81 crore was pending (under process/approved but payment pending). The total claims rejected by FGI stood at Rs 8.40 crore.
Following raising of concerns regarding suspected fraudulent claims involving some hospitals and submitting of “fraud dossiers” by FGI in December 2024, the NHPS claimed that it took immediate cognizance of the matter and independently verified the records through its internal audit teams and district authorities.
The findings revealed that majority of the claims flagged as fraudulent were either genuine or already under investigation by NHPS, and that the insurer failed to substantiate most of the allegations with adequate documentary proof.
The society said it had in good faith extended full cooperation and offered a joint verification mechanism to which the insurer had remained unresponsive.
Stating that FGI had currently withheld further claim payments, citing alleged frauds by empanelled hospitals, the NHPS maintained that this was in contravention of the contract provisions and the National Health Authority’s (NHA) Guidelines for Recoveries and other Actions Post Confirmation of Fraud and other Irregularities, as the alleged fraud cases had not yet been proven beyond reasonable doubt.
The society said the delay was further exacerbated by FGI’s lack of cooperation, despite earlier mutual agreement to resolve such cases through joint physical audits.
Despite repeated assurances from the state government to fully cooperate in recovering payments related to fraudulent claims and to support punitive actions wherever justified, and the commitment of the Nagaland Private Doctors’ Association (NPDA) to penalise erring hospitals, the society stated that FGI had failed to respond to requests to process and release genuine claims without arbitrary rejections.
According to the society, the state government had paid the full premium due — Rs 91.99 crore — to FGI as per the contract agreement. While remaining committed to ensuring accountability, the NHPS declared that it would not tolerate misuse of public resources, and stood firm against the blanket withholding of claims by FGI that adversely affected patients and empanelled hospitals.
Revealing that it had already suspended the empanelment of two hospitals for a period of six months, and initiated recovery from two hospitals, the society said this was this was an ongoing exercise, and further recoveries would be made against claims that were proved to be fraudulent beyond doubt.
The NHPS said the issue had been formally escalated to the Insurance Regulatory and Development Authority of India (IRDAI), National Health Authority (NHA), and Department of Financial Services (DFS), Union Ministry of Finance, with all relevant documents, including claim status, being shared with these agencies for regulatory intervention.
Further, the society stated that it was actively examining available legal and contractual options to ensure adherence to the service agreement signed with FGI, with deliberations being ongoing regarding appropriate penal and remedial actions.
As a stakeholder in the healthcare delivery in the state, the NHPS appealed all the private empanelled healthcare providers (EHCP) in Nagaland to continue with the services as the department was undertaking all efforts to resolve the non-payment issue.
And in the event of any empanelled private hospital in the state not willing to provide cashless services under CMHIS and PM-JAY due to the ongoing impasse, the society advised beneficiaries to visit any government hospital, CIHSR Dimapur or any empanelled hospital outside the state.
The society said all government hospitals, CIHSR Dimapur and empanelled hospitals outside the state would continue to provide uninterrupted and fully cashless treatment services under the schemes.
Reaffirming its commitment to the people on behalf of the state government, the NHPS claimed that every effort was being made to restore normalcy in the claim disbursement process, hold the insurer accountable, and ensure that no eligible citizen was denied timely and quality healthcare under CMHIS and AB-PMJAY. For further information, the society asked the public to contact its helpline 1800-202-3380.