Health Minister Says National Health Insurance Program Plagued by Widespread Abuse

Kathmandu — Nepal’s Health and Population Minister, Dr. Sudha Sharma Gautam, has acknowledged “significant abuse” in the national health insurance program and announced plans to implement stricter measures to curb misuse.

Speaking on Sunday as she unveiled the progress report of her first three months in office, Dr. Gautam said that service providers have been found to charge for services with improper intent, leading to excessive claims and financial strain on the insurance fund.

According to the minister, the insurance scheme has faced multiple challenges, including claims exceeding premium collections, delayed reimbursements, unnecessary utilization of services, weak claims management, low participation from the organized sector, and internal capacity constraints within the Health Insurance Board.

To address these issues, the ministry and the Health Insurance Board convened a national workshop and formulated a 19-point action plan, which includes revising benefit packages, prioritizing specialized care, eliminating duplicate services, setting separate spending limits for outpatient and inpatient care, clarifying referral standards, and revisiting co-payment rates.

Dr. Gautam also urged both citizens and healthcare providers to act responsibly, warning that unnecessary testing and treatment could exhaust limited insurance funds. Measures such as real-time SMS notifications of expenses and biometric identification for beneficiaries will be introduced to improve transparency and accountability.

The reforms come amid broader concerns that Nepal’s health insurance system is under strain, with some public hospitals halting insurance-based services due to delayed reimbursements and financial pressure.