The Nagaland Health Protection Society has clarified recent concerns regarding the suspension of services under the Pradhan Mantri Jan Arogya Maim (PM-JAY) and the Chief Minister Health Insurance Scheme (CMH1S) by certain empanelled hospitals in Nagaland.
The Department has reassured the public that the services under both PM-JAY and CMHIS are fully operational and have not been suspended. There was a miscommunication from the Insurance Company (FGI) which has now been resolved. All empanelled hospitals have been duly informed that these services will continue without interruption. The PM-JAY and CMHIS services remain active unless a hospital unilaterally decides to suspend them, which would be in violation of the signed Memorandum of Understanding (MoU).
It also mentioned that a total of Rs. 53.64 Crores for claims under AB PM-JAY and CMHIS (General) and Rs. 34.54 Crores for claims under CMHIS (EP) has been paid to various empanelled hospitals during FY 2023-24. For the current fiscal year 2024-25, Rs. 38.92 Crores for claims under AB PM-JAY & CMHIS (General) and Rs. 33.52 Crores under CMHIS (EP) have already been disbursed within Nagaland. Claims paid for treatment availed outside Nagaland amount to Rs. 3.99 Crores under PM-JAY and Rs. 3.81 Crores under CMHIS (EP) in FY 2023-24, and Rs. 1.95 Crores under PM-JAY and Rs. 10.16 Crores under CMHIS for FY 2024-25.
It stated that the utilization of premiums is growing annually at a compounded rate of 17%, reflecting the increasing popularity of these schemes, which benefit patients across the state. However, there have been reports of alleged fraud and abuse/misuse, including financial exploitation of vulnerable patients by certain empanelled hospitals. Such practices jeopardize the sustainability of these schemes. The Department has initiated an investigation to examine all such allegations and ascertain the commitment of any fraud or abuse by hospitals. Strict actions will be imposed on any hospital found violating guidelines or statutory compliance. In the meantime, the incumbent Insurance Company (FGI) is committed to release the claims amount of genuine cases.
The Department also informed that both PM-JAY and CMHIS schemes provide cashless services for beneficiaries at empanelled hospitals. Beneficiaries are not required to make any upfront payment for treatments covered under the scheme unless the patients ask for services not entitled. Instead, the treatment costs are directly settled between the empanelled hospital and the insurance company. This ensures that financial barriers do not prevent eligible households from accessing quality healthcare services.
Beneficiaries are urged to verify their eligibility and visit any empanelled hospital for cashless treatments. For further assistance or clarification, the public may contact the toll- free helpline Number: 1800-202-3380.
For Public Advisory, all stakeholders, including hospitals, are advised not to issue hasty notices regarding service suspension without confirmation from the competent authority. Such actions may cause unnecessary confusion among the public. Furthermore, concerned citizens are encouraged to report any unethical practices by hospitals.
(DIPR)