KATHMANDU, Jan 21: Tribhuvan University Teaching Hospital (TUTH) resumed health insurance services on Monday after a long suspension. The hospital's director, Dr Ghanshyam Gurung, explained that the Health Insurance Board’s decision to remove the benefit package led to the resumption.
The hospital refused to implement the package introduced by the board in Bhadra (mid-August to mid-September) due to inconsistent pricing of services and materials. “The cost of heart medication fell below the hospital's purchase price, and the same applied to other materials,” said Dr Gurung. The TUTH had suspended the health insurance program for the last five months.
Dr Gurung said that while the package seemed convenient for outpatient department (OPD) patients, it proved impractical for critically ill or admitted patients.
Dr Saroj Sharma, the acting executive member of the board, announced the cancellation of the benefit package and decided to provide payments to patients based on the cost of each service and material. The board had implemented this service for all hospitals in Bhadra, but TUTH in Maharajgunj and the Manmohan Cardiothoracic Vascular and Transplant Center refused to implement it.
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After receiving complaints from other hospitals about the refusal, the board conducted on-site monitoring and canceled the benefit package. Dr Sharma revealed that the hospitals rejected the program because treating patients with long hospital stays under the package caused financial losses. Moreover, the high cost of materials required for certain complex diseases made it impractical to effectively set the program into motion.
Although the benefit package has been canceled, the Health Insurance Board still owes the hospital millions, creating ongoing issues, said the hospital's director, Dr Gurung.
He disclosed that the board has not paid Rs 690 million to the hospital. The outstanding amount has accumulated since the hospital started the health insurance program in 2020.
Among the outstanding payments, the board still needs to review a claim for Rs 200 million, while it has rejected a Rs 10 million claim. Dr Gurung said the hospital is facing difficulties due to the payment delays and the rejection of the Rs 10 million claim. "The board tends to pay Rs 20 million at once but leaves Rs 200 million unpaid, resulting in a large outstanding balance," he explained.
With such a significant amount pending, the hospital is struggling to manage daily and emergency expenses, Dr Gurung noted. "When equipment breaks down, we need to purchase it immediately. But we haven’t been able to buy it due to the outstanding amount. It's a huge sum," he added.
Dr Saroj Sharma, the acting executive director of the Health Insurance Board, clarified that the payment delays occur because insurance staff must review and verify claims across the country before confirming them.
The board processes outstanding payments within a three-month interval. Dr Sharma explained that the issue arose because the board couldn't verify claims on time across the country. The board still owes Rs 11 billion in payments to hospitals nationwide, including TUTH. It also reported that 27 percent of the total population is currently enrolled in the health insurance program.
