Dr. Subas Pyakurel explains how health insurance protects families from financial crisis

KATHMANDU: Treatment expenses can plunge many families into financial crisis. To reduce such risks, the government has been operating the Health Insurance Program. Under the program, a family of up to five members can contribute Rs 3,500 annually and receive treatment facilities of up to Rs 100,000. However, many people have queries regarding whether all treatment expenses are covered after getting insured, which hospital one should go to, and what to do once the benefit limit is exhausted.

Citizens who have health insurance have also been complaining that they do not get medicines at hospitals and that treatment services are not smooth. Here is an edited excerpt of the conversation between Health Insurance Board Chairman Dr. Subas Pyakurel and Shasindra Gautam regarding the necessity of health insurance, the process of joining, treatment facilities, problems in service delivery, and reform plans:

What is health insurance in simple terms? Why is it necessary?

Not all individuals fall sick all the time. But the possibility of falling sick at some point or another exists for everyone. The risk may vary for certain diseases, but understood generally, the possibility of falling sick remains for all of us.

Therefore, health insurance is a system where many people contribute small amounts of money while they are healthy so that they can obtain major financial assistance for treatment at the time they fall sick. This is a health protection program. Globally, it is taken as a part of social security. There are statistics showing that a situation where treatment expenses have to be paid from one’s own pocket or savings can push people toward poverty. Health insurance helps protect against such financial risks.

The health insurance program operated in Nepal allows a family to receive treatment facilities of up to Rs 100,000 annually. Let’s look at our own households; how many times does a situation arise where we have to spend Rs 100,000 for treatment in a year? Therefore, this facility can provide major relief to many families. It should be understood as a foundation of financial security.

How much has to be paid annually when getting health insurance? How much treatment facility is received in return?

A family of up to five members must contribute Rs 3,500 annually. If there are more than five members, the contribution amount is added at the rate of Rs 700 for each additional member.

Health Insurance Board Chairman Dr. Subash Pyakurel

We have more than 500 hospitals and health institutions affiliated across the country. Treatment facilities specified by the program can be taken from those institutions. There is a treatment facility of up to Rs 100,000 annually for a family of up to five members.

We have been paying the treatment expenses for specified services to the respective hospitals. Our effort is to include as many services as necessary when falling sick as possible in this. However, since this is an insurance program, it has certain rules and limits. All types of treatments and expenses are not covered. Treatment expenses are paid only according to the services and facilities specified by the program.

How to do health insurance? Can it also be done online?

Now we have made the process of getting insurance easy by using technology. Technology must be adopted according to the times. Therefore, we have developed an online system. One can apply themselves through the e-portal of the Health Insurance Board. Those who do not know how to do the online process can also take the help of other family members.

We have done the work of linking this system with the National Identity Card. Putting in the National Identity Card number allows many details to be obtained directly from the system. After filling in the necessary details, the contribution amount can be paid through digital payment mediums. There is an arrangement to pay through mediums such as ConnectIPS. After that, insurance-related details can be obtained digitally.

Another method is through registration assistants. Registration assistants have been arranged for every ward. If their name and contact number are not known, inquiries can be made with the ward office or ward chairperson. Nowadays, the number of citizens coming to do insurance online is also increasing.

Does one have to reach the ward or district of the permanent address itself to do health insurance?

It is not required. Since insurance can now also be done from the online system, it is not necessary to reach the ward or district of permanent address itself. However, the authenticity of the address and other details placed in the application must be verified. For that, there is an arrangement for verification from the respective district and provincial levels. After verification, information about it can be obtained from the online system itself.

Details can be obtained from the National Identity Card. If that is not available or if technical problems arise, there is an arrangement to upload necessary documents. There may also be situations where family relationships need to be disclosed. Since the financial aspect is attached to insurance, it is necessary to ensure the authenticity of details. But for that, one does not mandatorily have to reach the place of permanent address.

If there are seven to eight members in a family, is it enough if only one person does insurance or must everyone do it?

According to the current legal arrangement, this is a family-based program. One person in the family is designated as the head of the household and other members are included under that same family. Therefore, it is not that insurance by just one person automatically insures all members of the family. The details of members included in insurance must also be registered.

Health Insurance Board Chairman Dr. Subash Pyakurel

We have also been obtaining and updating details of some target groups from other bodies of the state and local levels. But for family-based insurance, the official details of members must be ensured. Since financial liability is also attached to this, attention must be paid to the authenticity of details just like in banking transactions.

Is there an age limit for doing health insurance? Can senior citizens, children, and chronic patients also join?

This program is open for persons of any age group. There is an arrangement to provide treatment facilities to a newly born infant as well through the insured mother up to a certain period.

Senior citizens can also join this. Most come through family-based insurance. In the case of senior citizens above 70 years of age, there is an arrangement to obtain details even by using other data of the state. Therefore, it is not that one cannot join the program due to age. In family-based insurance, however, there is an arrangement to designate a household head.

After getting health insurance, can one get treatment at any hospital across the country or must one go to hospitals specified by the board?

The initial characteristic of health insurance or any insurance is that service must be taken from a specified place. Treatment must be taken from hospitals and health institutions affiliated with our program. More than 500 service-providing institutions are affiliated nationwide.

There is also an arrangement to pay for emergency treatment in some private hospitals. But for that too, the respective hospital must be affiliated with the Health Insurance Board. Therefore, it is not that treatment expenses are received by going to any hospital just by getting insurance. Service must be taken according to specified rules from health institutions affiliated with the program.

There is an understanding that persons with cancer, kidney, and heart diseases do not get treatment expenses even if they have health insurance. What is the reality?

That is not the case. We must be clear on this. There are various treatment assistance schemes of the government. According to the benefit package under the health insurance program, treatment facilities of up to Rs 100,000 are received.

Besides that, there is another scheme for eight types of critical illnesses specified by the government. Patients with such diseases can obtain facilities of up to an additional Rs 100,000 under the respective scheme. Therefore, the understanding that persons afflicted with cancer, kidney, or heart disease do not get treatment facilities from health insurance at all is not correct. How much facility is received for which disease depends on the rules of the respective scheme.

There are complaints that medicines are not found in hospitals and treatment is not good even after getting health insurance. What do you say to this?

Health insurance is one of the backbones of the health system. But in this, hospitals, health workers, and the insurance board all have roles. Recently too, we have monitored some hospitals. We have asked hospitals how service can be made smooth and what kind of complaints there are.

We have the right to ask questions about service delivery on the basis of agreements made by hospitals with us. If a complaint comes that insured patients did not get the service they should have, it must be accepted and taken seriously.

Interviewer Shasindra Gautam (right) in a conversation with Health Insurance Board Chairman Dr. Subash Pyakurel (left)

We have taken such complaints seriously. Efforts to solve problems are ongoing one by one with affiliated hospitals. The work of issuing necessary circulars, giving directives, and checking whether they are implemented or not is also being done.

If the family’s treatment facility equivalent to Rs 100,000 is exhausted, what happens after that? Do patients have to pay expenses themselves?

In this, how the benefit of the insurance program is distributed must also be understood. Currently, there is a limit of up to Rs 25,000 annually for outpatient department or OPD service. The remaining facility can be utilized for emergency treatment or treatment done by being admitted to the hospital.

The limit of Rs 100,000 for the family is for all insured members of the family. That amount can also be spent on the treatment of a single patient. The hospital’s system has details of how much has been spent and how much remains.

Generally, after the facility limit is exhausted, additional treatment expenses are not paid from that same scheme. After that, patients have to arrange expenses themselves. But as said earlier, there is another scheme for critical illnesses specified by the government. In the event of having such a disease, the hospital can coordinate with us and advance the process of whether it is permissible to move from one scheme to another scheme.

Therefore, it is not that in all conditions additional facilities are automatically received after Rs 100,000 is exhausted. Additional facilities can be obtained only according to the respective disease, scheme, and rules.

If a complaint related to health insurance comes, is it addressed? Where to contact?

It is addressed. To make it easy for insured citizens and the general public, we have kept a four-digit 1161 hotline number. Currently, complaints are being addressed during daytime hours on this number. In the near future, we plan to make arrangements where complaints can also be taken during nighttime hours.

For that, work is also underway on the option of using artificial intelligence (AI) or forwarding calls. Addressing complaints does not mean just listening to complaints but also understanding what problem happened in which hospital, forwarding information about it to the respective place, and advancing toward a solution.

What are the main challenges faced by the board while operating the health insurance program?

This is a program of a social nature. It cannot be operated from the perspective of earning profit like commercial insurance. The first challenge is of financial resources. The contribution amount raised from the insured is not sufficient for operating the program. Therefore, the program also needs financial assistance from taxes and other sources of the state.

The second challenge is the gap between citizens’ expectations and available facilities. After getting insurance, there is an expectation that additional and smooth service will be received. But when everything cannot happen according to that expectation, problems created due to other reasons also end up resting on health insurance.

The third challenge is manpower and institutional structure. We need everything from technical manpower to permanent positions and institutional structures. Work to organize that is underway. Another challenge is claim management of treatment expenses. Many claims arrive, and problems occur in their testing and payment. Currently, we have kept solving these problems as a priority by improving the digital system and work procedures.

There are also diseases where treatment expenses cost more than Rs 100,000. What is the board’s plan to prevent a situation where even homes and land have to be sold for treatment?

Looking at examples of various countries of the world, practices are found where a certain scheme provides basic protection while for needs beyond that, there is cooperation with other schemes.

We are also working on such a possibility. We are looking at whether technical systems can be connected so that after the facility of one scheme is exhausted, one can move to another scheme. For that, management of contribution amounts can be arranged to cooperate with other insurance companies as well. There is also the possibility of linking health insurance with other programs of the state.

Health Insurance Board Chairman Dr. Subash Pyakurel

Likewise, provincial and local governments can bring schemes to give additional treatment facilities for their citizens. Such schemes can be made to provide additional support in situations where the basic facility of health insurance cannot sustain it. For this, coordination and cooperation with various bodies are being advanced gradually.

How is the attempt to make fake documents and claim treatment expenses controlled?

We have a system to review claims. A team of doctors and other manpower of the health sector is involved in it. Treatment expense claims submitted by hospitals are tested through the system. It is rechecked whether details are present according to the protocol that must be followed in the respective treatment. Now, to make this process more effective, we are preparing to use AI. The plan is to increase the use of technology in the testing of treatment details and claims.

What do you want to say to citizens who have not done health insurance yet?

I urge them to understand experiences with persons who have already taken health insurance services. When meeting family and relatives, if someone has got treatment from insurance, ask about it. We have seen that persons who have taken service from insurance understand its importance much better.

I will tell my own experience. Once at a time when I went outside Kathmandu, a situation arose where surgery had to be done emergently. I took treatment from a government hospital. At that time, because I had health insurance, I felt much relieved. Preparation according to that for emergency treatment was also not there.

In my memory, only about Rs 2,300 was spent at that time. I got surgery done and stayed in the hospital. The next day I reached the ward from the post-operative room and then was discharged. Therefore, the importance of health insurance is known much better after taking service.

Instead of just listening to negative comments made by others or reading things that appeared in media, one should understand its real facilities and rules. Health insurance also has a scientific aspect. If arrangements are made to provide necessary treatment and stop unnecessary tests and expenses, it becomes easy for doctors, nurses, other health workers, hospitals, and citizens alike.

Patients should also not try to get unnecessary tests done. In this, all parties have a role. The more successful health insurance is, the more it helps make the health service system organized and effective. Therefore, I warmly request everyone to take ownership of it.