NHPS directs hospital to review disputed CMHIS newborn claim as Dimapur facility says eligible add-ons may cover entire medical bill
DIMAPUR — The Nagaland Health Protection Society (NHPS) has directed an empanelled private hospital in Dimapur to process a disputed neonatal treatment claim strictly under the Chief Minister's Health Insurance Scheme for Employees and Pensioners (CMHIS-EP), while the hospital has expressed confidence that the newborn's entire medical bill could eventually be covered under the scheme after eligible add-on claims are processed.
The development comes a day after a government employee alleged that despite being enrolled under CMHIS-EP, he was asked to pay more than INR 5.15 lakh for his premature newborn's treatment at Eden Medical Centre after the insurance scheme reportedly covered only INR 1.63 lakh of a total bill of INR 6.79 lakh.
The beneficiary had claimed that while his wife's treatment expenses were largely settled under CMHIS-EP, the hospital informed him that most of the expenses incurred during his baby's prolonged stay in the Neonatal Intensive Care Unit (NICU) would have to be borne by the family.
Responding to the grievance, the NHPS released a statement informing that it had taken up the matter with the empanelled hospital and reminded it of its obligations under the Empanelment Agreement and the Memorandum of Understanding signed with the State Health Authority.
Read more: Nagaland: Government employee questions CMHIS-EP after INR 5.15 lakh NICU bill
The society stated that empanelled hospitals are required to provide cashless treatment to all eligible Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana (AB PM-JAY) and CMHIS beneficiaries in accordance with approved package rates and scheme guidelines.
It further advised the hospital to process the claim strictly under the applicable CMHIS package provisions and refrain from recovering any amount from the beneficiary except in circumstances expressly permitted under the scheme.
Clarifying the scheme provisions, NHPS stated that NICU bed charges are covered under the approved Health Benefit Packages, while paediatric care for newborns, where applicable, is also covered in accordance with the scheme guidelines. It added that separate add-on packages are available for oxygen therapy, laboratory investigations and diagnostic services.
The society also clarified that medicines are reimbursable through the open billing mechanism, with claims settled either at the National Pharmaceutical Pricing Authority (NPPA) ceiling rates or at the actual cost of the medicines.
Consultation charges, it reminded, are already included in the approved package rates and cannot be billed separately, except in approved cross-consultation cases specifically permitted under the scheme.
The NHPS underscored that all package provisions and claim settlement mechanisms available under CMHIS must be fully utilised before concluding that any expenditure falls outside the scheme's coverage.
It reiterated that no additional amount may be recovered from beneficiaries except for non-payable consumables specified under the Insurance Regulatory and Development Authority of India (IRDAI) guidelines, such as diapers and toiletries, or when beneficiaries voluntarily opt for higher room categories or implants beyond their entitlement.
NHPS Chief Executive Officer Thavaseelan K urged both beneficiaries and empanelled hospitals to approach the society first to facilitate timely resolution of disputes and avoid unnecessary escalation. Beneficiaries have also been advised to contact the NHPS toll-free helpline (1800-202-3380) through phone or WhatsApp to seek assistance or lodge grievances.
Meanwhile, Eden Medical Centre, in a statement issued late Wednesday, maintained that the infant—born prematurely at around seven months of gestation and weighing just 920 grams—required 64 days of intensive neonatal care, including continuous oxygen therapy, CPAP support, specialised monitoring, medications, laboratory investigations and round-the-clock nursing care.
The hospital stated that the approved CMHIS package for neonatal intensive care provides INR 1,400 per day covering consultation, nursing, ICU bed charges and phototherapy, while eligible add-on services such as oxygen therapy and laboratory investigations are separately claimable. It also pointed out that certain consumables, including diapers and baby food, are specifically excluded from insurance coverage under IRDAI guidelines.
According to the hospital, the baby's parents were informed at the time of admission that the CMHIS package might not fully cover the expenses arising from the prolonged NICU stay and had signed a written consent agreeing to bear any non-covered charges.
However, the hospital contended that it subsequently approached NHPS seeking guidance on recovering expenses beyond the approved package. Following NHPS's advice, it is now processing all eligible add-on claims under the scheme and expressed optimism that, once the process is completed, the patient's entire bill would be accommodated under CMHIS.
The hospital also stated that it had made repeated attempts to contact the baby's father regarding the matter before the issue was raised publicly, but alleged that media statements made before completion of the claims process had caused reputational harm. It added that it is seeking legal advice and reserves its rights under the law.