Teaching hospital health insurance services resume following the conclusion of the benefit package

After a protracted break, Tribhuvan University Teaching Hospital (TUTH) started offering health insurance services again on Monday. Dr. Ghanshyam Gurung, the hospital’s director, clarified that the resumption was caused by the Health Insurance Board’s decision to eliminate the benefit package.

Due to uneven service and material prices, the hospital declined to execute the board-introduced package in Bhadra (mid-August to mid-September). According to Dr. Gurung, “The price of the heart medication was less than the hospital’s purchase price, and the same was true for other materials.” For the past five months, the health insurance program has been halted by the TUTH.

According to Dr. Gurung, the package appeared realistic for patients in the outpatient department (OPD), but it was not feasible for patients who were admitted or in severe condition.

The board’s acting executive member, Dr. Saroj Sharma, said that the benefit package would no longer be offered and that patients would instead be paid according to the price of each service and item. The Manmohan Cardiothoracic Vascular and Transplant Center and TUTH in Maharajgunj declined to adopt this service, despite the board having done so for all of Bhadra’s hospitals.

The board withdrew the benefit package and carried out on-site surveillance after other hospitals complained about the rejection. According to Dr. Sharma, hospitals have turned down the initiative since it has resulted in financial losses in treating patients who require lengthy hospital stays. Furthermore, it was not feasible to successfully launch the program because of the high expense of the components needed for some difficult disorders.

The hospital’s director, Dr. Gurung, stated that despite the cancellation of the benefit package, the Health Insurance Board still owes the hospital millions, causing continuous problems.

He revealed that the hospital has not received Rs 690 million from the board. Since the hospital began the health insurance program in 2020, the outstanding balance has grown.

The board has rejected a claim for Rs 10 million and still needs to consider another claim for Rs 200 million among the pending payments. According to Dr. Gurung, the hospital is having problems as a result of the payment delays and the denial of the Rs 10 million claim. “The board tends to pay Rs 20 million at once but leaves Rs 200 million unpaid, resulting in a large outstanding balance,” he said.

According to Dr. Gurung, the hospital is finding it difficult to cover both routine and urgent costs because of the sizeable amount that is still outstanding. “When it malfunctions, we have to buy new equipment immediately. However, we haven’t been able to buy it because of the unpaid balance. It’s a huge sum,” he continued.

The Health Insurance Board’s acting executive director, Dr. Saroj Sharma, explained that the reason for the payment delays is that insurance personnel must examine and validate applications nationwide before approving them.

Overdue payments are processed by the board every three months. Dr. Sharma clarified that the board’s inability to promptly verify allegations nationwide was the root of the problem. The board still owes TUTH and other hospitals around the country Rs 11 billion. Additionally, it stated that presently, 27% of the population is enrolled in the health insurance scheme.