The Nagaland Health Protection Society (NHPS) has issued a clarification on the provisions of the Chief Minister Health Insurance Scheme (Employees & Pensioners) [CMHIS (EP)] following a grievance raised by a beneficiary over additional charges incurred during a prolonged Neonatal Intensive Care Unit (NICU) admission at an empanelled hospital.
According to NHPS, the beneficiary was billed an additional Rs. 5,15,704 by the hospital, while only Rs. 1,63,975 was processed and settled under the scheme as the eligible claim amount.
Taking cognisance of the matter, NHPS said it had taken up the issue with the concerned empanelled hospital and reiterated the provisions of the CMHIS scheme.
It clarified that NICU bed charges are covered under the approved CMHIS Health Benefit Packages. The scheme also provides coverage for paediatric care for newborns, wherever applicable, along with separate add-on packages for oxygen support, laboratory tests and diagnostic investigations.
NHPS further stated that medicines are reimbursable through the Open Billing mechanism, with claims settled according to the ceiling prices fixed by the National Pharmaceutical Pricing Authority (NPPA) or the actual cost of the drugs.
Regarding consultation fees, the Society clarified that consultation charges are already included in the approved package rates and not payable separately. Additional consultation charges are admissible only in cases of approved cross-consultation cases where such provisions exist under the scheme guidelines.
The Society emphasised that all available package provisions, approval processes and claim settlement mechanisms under CMHIS must be fully explored and appropriately utilized before concluding that any expenditure is not covered under the scheme.
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Reiterating the cashless nature of the scheme, NHPS stated that empanelled hospitals are prohibited from recovering additional charges from beneficiaries except for non-payable items specified under the Insurance Regulatory and Development Authority of India (IRDAI) guidelines, such as diapers and toiletries, or where beneficiaries voluntarily opt for higher room categories or higher-value implants beyond the scheme entitlement, as expressly permitted under the Scheme Guidelines. In all other circumstances, treatment under CMHIS must remain completely cashless and recovery of any outstanding amount from the beneficiary is not permissible.
NHPS also reminded the hospital that it had signed a Memorandum of Understanding (MoU) with the State Health Authority at the time of empanelment, agreeing to provide cashless treatment to eligible AB PM-JAY and CMHIS beneficiaries in accordance with approved package rates and scheme guidelines.
Accordingly, the concerned empanelled hospital has been advised to process the claim strictly as per the applicable CMHIS package provisions and the CMHIS Scheme Guidelines and refrain from recovering any amount from the beneficiary except where expressly permitted under the scheme.
Reaffirming its commitment to protecting the interests of beneficiaries, NHPS said it would continue to ensure that all empanelled healthcare providers adhere to the scheme guidelines.
The Society also urged beneficiaries and empanelled hospitals to contact NHPS at the earliest in the event of any dispute or difficulty so that issues can be resolved promptly without unnecessary escalation.
Beneficiaries of AB PM-JAY and CMHIS can seek assistance or register grievances through the NHPS toll-free helpline 1800-202-3380 via call or WhatsApp.
