Nagaland Health Protection Society (NHPS), the implementing agency of the Ayushman Bharat Pradhan Mantri Jan Arogya Yojna (AB PM-JAY) and Chief Minister Health Insurance Scheme (CMHIS), has urged all stakeholders including beneficiaries, empanelled hospitals, insurance companies etc. to utilize the schemes’ benefits judiciously and ethically.

Calling for responsible utilization and adherence to ethical practices, the NHPS emphasized that Public Health Insurance Schemes operate on the core principle of risk-pooling resources to provide financial security against unforeseen medical expenses and preventing out of pocket expenditure for hospitalised care and promoting access to quality healthcare for the people. It reminded that rational use and diligent implementation will ensure the long-term sustainability of this noble initiative, however, abuse or misuse can compromise the scheme’s viability, undermining its intended purpose.

In a press release, NHPS explained that AB PM-JAY provides annual insurance cover of Rs. 5.00 lakhs per household and the CMHIS provides annual insurance cover of Rs. 20.00 lakhs per household for Employees and Pensioners and Rs. 5.00 lakhs per household for families who are not covered under AB PM-JAY or not a Government Employee or Pensioner.

It informed that the CMHIS is financed by converting 50% of the monthly medical allowance of employees and pensioners and the corpus is maintained by the Finance Department in a dedicated Savings Bank Account. Any additional expenditure beyond the insurance cover of Rs. 20.00 lakhs per household for Government Employees is reimbursed through the Salary head of the concerned department.

The Nagaland Health Protection Society highlighted that AB PM-JAY is financed by the Central and State Governments in the ratio 90:10. However, the Central share for premium is capped at 90% of Rs. 1052/- per Household and any excess amount beyond this ceiling is paid by the State Government in addition to the 10% State Share. As a result, for the Policy Year 2024 – 25, the State Government’s Share is 51% and the Central Government’s Share is 49%.

It also stated that the insurance company is selected through a national competitive tender open to all IRDAI registered health insurance companies operating in the country and that the selection process is in compliance with the tendering guidelines issued by the National Health Authority (NHA) for selecting insurers. The selected insurance company is responsible for claims processing, approval of claims and payment of claims to the empanelled hospitals, the NHPS said.

It added that there is no default on payment of premium to Future Generali India Insurance Co. Ltd (FGI), the implementing insurance company for the schemes for the period of April 2024 to March 2025. The NHPS stated that out of the total premium of Rs. 92 crores to be paid in 3 instalments to FGI for the current policy period, a total of Rs. 90 crores (upto 3rd instalment of state share and 2nd instalment of central share) have been paid to the insurance company as of date. It also highlighted that as per Insurance Regulatory and Development Authority of India (IRDAI) regulations, insurance coverage cannot commence without upfront premium payment and therefore the premium payments are made to the insurance company immediately upon fund release by the Government.

It informed that the discovered premium payable to the insurance company is Rs. 1950/- per household for insurance cover of Rs. 5.00 lakhs (AB PM-JAY and CMHIS General Category) and the premium for CMHIS (EP) is Rs. 3860/- per household for insurance cover of Rs. 20.00 lakhs.

Further, the NHPS highlighted that as of February 16, 2025, the following claims have been processed by the Insurance Company:

For PMJAY:

– A total of 30,379 claims amounting to Rs. 57.34 crores have been approved.

– Of these, 22,914 claims totalling Rs. 42.71 crores have been paid to various hospitals.

For CMHIS:

– A total of 17,501 claims amounting to Rs. 72.32 crores have been approved.

– Out of these, 11,638 claims totalling Rs. 47.20 crores have been paid to various hospitals.

For further information and clarification, citizens are encouraged to call the NHPS Helpline (Toll-Free No: 1800-202-3380) or email support-nhps@cmhis.nagaland.gov.in