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.
Insurance authority issues directives on monetary loss insuranc...
The figures paint an even more troubling picture. Of nearly 9.8 million insured individuals, only 6.2 million remain active. Among them, 55 percent belong to targeted groups whose premiums are fully subsidised by the government, costing between Rs 4 billion and Rs 5 billion annually. The remaining 45 percent contribute premiums themselves, generating roughly Rs 3.5 billion. While annual collections hover around Rs 13 billion, claim payments have soared to Rs 26 billion, making the fund’s imbalance inevitable. The government maintains that billions of rupees beyond the allocated budget have already been paid from the state treasury in the current fiscal year alone. Speaking at a recent programme, Minister for Health and Population Dr Sudha Sharma Gautam issued a stern warning. She said the Health Insurance Board’s spending without securing adequate resources or obtaining the Finance Ministry’s consent has imposed a heavy burden on the state. Noting that Rs 10 billion has already been spent on health insurance this fiscal year, she said annual liabilities are projected to reach Rs 24 billion. “The government does not pluck money from trees,” she remarked, underscoring that unchecked spending ultimately falls on taxpayers. According to her, the assumption that the government will automatically cover deficits without secured funding has pushed the system towards crisis. Hospitals’ roles have also come under scrutiny. Reports of unnecessary tests, inconsistent rate structures, and concerns about the quality of medicines and services point to weak regulatory oversight. With the Insurance Board largely confined to the role of payer, the Ministry of Health and other monitoring agencies have struggled to enforce accountability effectively. Although the federal structure envisions financial contributions from provincial governments, in practice, the burden appears to fall almost entirely on the federal government.
Public health experts argue that the root problem lies in the weakness of primary healthcare services. If basic health services were reliable and accessible, minor ailments would not escalate into costly hospital treatments covered by insurance. The Constitution guarantees free basic healthcare as a fundamental right and assigns its implementation primarily to local governments. However, local authorities have not been able to make healthcare sufficiently effective or accessible, placing additional pressure on the insurance system. Reform now demands clear direction and decisive action. Strengthening primary healthcare would significantly reduce the strain on insurance. Hospitals must adhere strictly to standardised rate structures and service packages. Transparent digital monitoring of services and payments is essential. Financial responsibilities among federal, provincial and local governments must be clearly defined and enforced. Gradually transitioning from a voluntary to a mandatory insurance model, particularly by incorporating the formal sector, could also strengthen the fund’s sustainability. Health insurance is directly tied to citizens’ lives and livelihoods. Allowing it to falter under weak policy design and disorderly spending would erode the treatment security of the poor and middle class. Without timely reform, today’s warning signs could become tomorrow’s full-blown crisis.
