Health Secretary Devkota Announces Strict Measures Against Health Insurance Irregularities

Kathmandu. Health Secretary Bikash Devkota has stated that the ministry has undertaken special homework to stop the extreme irregularities and misuse seen in the health insurance program. Speaking at a meeting of the Development, Economic Affairs and Public Administration Committee on Tuesday, he clarified that the misuse of insurance has put a huge burden on the state's treasury, and therefore, strict action will now be taken ruthlessly. He pointed out that at present, people who do not even need it are using insurance money for expensive tests like 'whole body checkup' in hospitals. He said that the system itself is in crisis because insurance is being misused by getting unnecessary tests done, when it should only be used for treatment in difficult and sensitive situations. Secretary Devkota informed that the ministry is moving forward with the process of revising the rates, as the health insurance has reached an unsustainable situation due to hospitals not managing the rates related to health insurance services properly and setting high rates by mixing private and government rates. Mentioning that the health insurance will be fully restructured through the upcoming budget, Secretary Devkota claimed that the ministry is working to reduce the health insurance expenses by 40 to 50 percent and make the system sustainable. Currently, the annual budget for the health insurance program is between approximately 10 to 12 billion rupees, but it is estimated that if improvements are not made in time, the annual expenditure could reach up to approximately 24 billion rupees. He said that insurance claims of about 2 billion rupees are coming in every month, and to manage this, it is necessary to understand the root cause of why so many claims are being received. Discussing the policy and practical aspects of insurance, Secretary Devkota said, 'Sometimes we say a lot, but the reason behind it is also important. The Insurance Act came in 2074 BS. This act, which came after the constitution was formed in 2072 BS, included health-related matters under the fundamental rights guaranteed by the constitution in insurance. Therefore, as I said earlier, the provision of providing free basic health services was also linked to insurance. On the other hand, budgets are going from various sources for basic health services at the provincial and local levels. This creates duplication in some cases. That needs to be removed.' He added, 'Secondly, it appears that some patients visiting hospitals are making claims with the mentality of getting a 'whole body checkup' or 'using the insurance amount of up to one lakh rupees in any way'. There is a thought to utilize the insurance amount. Perhaps we have not been able to ensure this sufficiently - that money is not for spending in normal circumstances, it is kept by the state to help in difficult times. If used only when absolutely necessary, the burden of insurance will decrease. It is better not to spend on things like whole body checkups right now.' He said, 'Thirdly, some hospitals do not seem to have organized their procedures systematically. The insurance rates also seem to be set at a somewhat high level. How that rate was determined is by mixing the rates of private and government hospitals and setting an intermediate rate. That rate is currently in the process of revision, because if a high rate like MRP is set, the expenses will not decrease. Therefore, it will be revised.' He added, 'Another point is that if anyone is found to have committed fraud or any irregularity, the Insurance Act itself has a provision for a fine of up to 5 lakh rupees. Such individuals must be punished according to the law. If these four-five measures can be implemented, the insurance expenses can be reduced by 40 to 50 percent. However, while reducing expenses, the basic health service under the fundamental rights of the people must be ensured. The state must continue to provide that service. Also, the treatment of those who cannot afford treatment expenses after falling ill should be covered by insurance; healthy individuals should not use insurance for tests to see 'if I am okay or not'. Because the state cannot yet afford to bear the financial capacity to reach that level.' Secretary Devkota warned that legal provisions exist to fine those who commit fraud by submitting irregularities and false details up to 5 lakh rupees according to the Insurance Act, and this will be strictly enforced in the coming days. He emphasized the need for mutual coordination, honesty, and responsible utilization among patients, service provider hospitals, and citizens receiving services to make the health insurance system long-term and sustainable.