• Over 72% of approved claims already settled
• NHPS urges ethical utilisation for sustainability
Kohima, February 20 (MExN): As of February 16, 2025, a total of Rs89.91 crore has been paid to various hospitals under the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) and the Chief Minister Health Insurance Scheme (CMHIS).
Of this, Rs 42.71 crore has been paid to hospitals for 22,914 claims under AB-PMJAY, while disbursal under CMHIS stood at Rs47.20 crore for 11,638 claims, informed the Nagaland Health Protection Society (NHPS), the implementing agency of the two schemes in the State.
As per the status, under AB-PMJAY, the implementing insurance company, Future Generali India Insurance Co. Ltd (FGI), has settled 22,914 out of 30,379 approved claims, indicating a settlement rate of over 75%.
At 11,638 out of 17,501 approved claims, the settlement rate was slightly lower for CMHIS at 66.50%.
Collectively, the settlement rate stood at over 72%, with 34,552 claims settled out of 47,880 approved.
In terms of monetary value, out of the total Rs 129.66 crore approved, Rs 89.91 crore has been paid to various hospitals for claims, indicating a settlement rate of 69.34% so far.
Meanwhile, the NHPS underscored that public health insurance schemes operate on the core principle of pooling resources to provide financial security against unforeseen medical expenses, preventing out-of-pocket expenditure and promoting access to quality healthcare for the people.
Rational use and diligent implementation will ensure the long-term sustainability of the initiative, while abuse or misuse can compromise the scheme’s viability and undermine its intended purpose, the Society stated.
Accordingly, given the limited resources, it urged all stakeholders, including beneficiaries, empanelled hospitals, and insurance companies, to ensure responsible utilisation and adherence to ethical practices.
The NHPS also informed citizens that they can call the NHPS Helpline (Toll-Free No: 1800-202-3380) or email support-nhps@cmhis.nagaland.gov.in for any clarification or information.
Financing of the schemes
The CMHIS scheme provides an annual insurance cover of Rs 20 lakh per household for government employees and pensioners (CMHIS-EP). The CMHIS general category scheme offers Rs 5 lakh coverage per household annually, the same amount provided under AB-PMJAY.
According to the NHPS, CMHIS is financed by converting 50% of the monthly medical allowance of employees and pensioners, with the corpus maintained by the Finance Department in a dedicated savings bank account.
Any additional expenditure above Rs 20 lakh per household for government employees is reimbursed through the salary head of the concerned department, it stated.
Further, AB-PMJAY is financed by the Union and State Governments in a 90:10 ratio.
However, the Union’s share of the premium is capped at 90% of Rs 1,052 per household, and any excess amount is paid by the State Government in addition to its 10% share, the NHPS highlighted.
As a result, for the policy year 2024-25, the State Government's share is 51%, while the Union Government's share is 49%, it added.
No default on payment
The NHPS further stressed that the selection of the insurance company for the schemes was done through a national competitive tender open to all health insurance companies in India registered under the Insurance Regulatory and Development Authority of India (IRDAI).
The selection process followed the Lowest Cost (L1) method in compliance with the tendering guidelines issued by the National Health Authority (NHA), it stated.
The selected insurance company is responsible for claims processing, approval of claims, and payment of claims to empanelled hospitals, it added.
For the current policy period (April 2024 – March 2025), the discovered premium payable to the FGI is Rs1,950 per household for AB-PMJAY and CMHIS General Category, and Rs 3,860 per household for CMHIS-EP, it informed.
The premiums, payable in three instalments, are made to the insurance company immediately upon fund release by the Government, as insurance coverage cannot commence without upfront premium payment, as per IRDAI regulations, it added.
According to the NHPS, out of the total premium of Rs 92 crore payable, Rs 90 crore (up to the third instalment of the State’s share and the second instalment of the Union’s share) has been paid.
Thus, there is no default on the payment of the premium to the insurance company, it asserted.
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