Frequently Asked Questions (FAQ) on Health Insurance Program Nepal

Health Insurance Program Nepal

1) What is Health Insurance?

Answer: Health Insurance is a government-operated program under Nepal’s Social Health Security initiative. It aims to reduce the financial burden of healthcare expenses and ensure access to quality healthcare services through a contribution-based financial protection system.

2) Is the Health Insurance Program operated by the government or private entities?

Answer: The Health Insurance Program is operated by the Government of Nepal.

3) What are the benefits of enrolling in the Health Insurance Program?

Answer: Upon paying the specified contribution, the insured individuals can receive healthcare services from enlisted health institutions. The benefits include:

• Increased access to healthcare services.
• Increased healthcare utilization rate.
• Reduction in out-of-pocket health expenditures and future medical costs.
• Improved overall health, leading to enhanced productivity and economic stability.
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4) What is the premium for Health Insurance?

Answer: The annual premium for a family of up to five members is NPR 3,500. If the family has more than five members, an additional NPR 700 is charged per extra member.

5) If a family has fewer than five members, is the premium still NPR 3,500?

Answer: Yes, for a family with one to five members, the annual premium remains NPR 3,500.

6) What is the maximum health coverage provided under the Health Insurance Program?

Answer:

Family Members	Contribution Amount	Coverage Limit
1-5 members	NPR 3,500	NPR 100,000
6 members	NPR 4,200	NPR 120,000
7 members	NPR 4,900	NPR 140,000
8 members	NPR 5,600	NPR 160,000
9 members	NPR 6,300	NPR 180,000
10 or more members	NPR 7,000	NPR 200,000

7) Is the insured amount available to each family member individually or as a lump sum for the whole family?

Answer: The insured amount is allocated as a lump sum for the whole family. However, any single member can use the amount as needed for treatment.

8) How long does a hospital provide medicines under the insurance scheme?

Answer:

• For general patients, prescribed medicines are provided as per the doctor’s recommendation.
• For chronic patients, medicines for up to three months can be dispensed at once.

9) If the insured amount is exhausted before the end of the policy period, can the policy be renewed early?

Answer: No, if the insured amount is used up before the policy term ends, early renewal is not allowed. The renewal can only be done at the designated renewal period.

10) Does the insured amount get provided as cash to the beneficiaries?

Answer: No, the insured amount is not given as cash. The insured individuals must use their insurance card at registered health institutions, and the expenses are deducted from their insurance balance.

11) If the insured amount is not used in a year, can it be carried forward to the next year?

Answer: No, the unused insured amount does not roll over to the next year. The remaining amount is pooled into the program to support other insured members.

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12) When does the insurance policy become active after registration?

Answer:

Registration Period	Coverage Activation Date
Baisakh - Asar (April - June)	Bhadra 1 (Mid-August)
Shrawan - Ashoj (July - September)	Mangsir 1 (Mid-November)
Kartik - Poush (October - December)	Falgun 1 (Mid-February)
Magh - Chaitra (January - March)	Jestha 1 (Mid-May)

13) Why is the policy activation delayed instead of being immediate?

Answer: The delay in policy activation prevents individuals from enrolling only when they fall sick. This approach helps maintain financial sustainability and fairness in the program.

14) What is co-payment in health insurance?

Answer: Co-payment is a provision where insured individuals must pay a certain percentage of healthcare costs.

• 10% co-payment applies to services received at government healthcare providers.
• 20% co-payment applies when services are taken at private providers.
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15) How can one register for health insurance?

Answer: Health insurance registration can be done through designated enrollment assistants who visit homes or through local government offices. Renewals can be done via Nagarik App, Connect-IPS, e-Sewa, or Khalti.

16) If a person pays the insurance premium to an enrollment assistant, but the assistant fails to deposit the amount, what happens to their insurance?

Answer: If such a case arises, complaints can be lodged at the respective ward office, the Health Insurance Board’s toll-free number (1660-01-11224), or via email (feedback@hib.gov.np). Legal actions will be taken against the assistant, and the insurance will be reinstated.

17) Can a person enroll through an enrollment assistant from another ward?

Answer: No, individuals must enroll through their respective ward’s designated assistant.

18) If a person is living in a different place than their permanent address, where should they enroll?

Answer: Registration should be done in the place where the head of the family resides. The nearest primary health provider in that area will be designated for treatment.

19) What is a "Primary Healthcare Provider"?

Answer: It is the nearest government healthcare provider designated to offer primary healthcare services to the insured individual.

20) Can treatment be taken from another health institution if services are unavailable at the designated primary provider?

Answer: Yes, if the designated provider cannot offer the required treatment, a referral slip must be obtained to visit another registered facility.

21) What happens if a hospital refuses to provide services under the insurance program?

Answer: Complaints can be made to the Health Insurance Board via the toll-free number (1660-01-11224) or email (feedback@hib.gov.np). The board will take necessary actions to ensure service availability.

22) What should be done if the insurance card is lost?

Answer: A replacement card can be obtained by submitting an application to the district insurance office with a fee of NPR 50. Digital cards from Nagarik App and HIB Profile can also be used.

23) Can an insured person check their insurance details?

Answer: Yes, they can check details such as policy validity, designated provider, and remaining balance via the Nagarik App or HIB Profile App.

24) What is the insurance provision for senior citizens aged 70 and above?

Answer: Senior citizens above 70 years can get a free insurance card with coverage up to NPR 100,000. If needed, they can use the remaining family insurance coverage as well.

25) Are there special provisions for marginalized groups?

Answer: Yes, free health insurance is provided to extremely poor individuals, senior citizens, people with disabilities, leprosy patients, HIV-infected individuals, and MDR-TB patients.

26) What discount is available for Female Community Health Volunteers?

Answer: Female Community Health Volunteers receive a 50% discount on family insurance contributions.

27) How is a newborn insured under the program?

Answer: If a child is born during the active insurance period of the mother, the child will be insured under the mother’s policy until renewal, after which the child must be enrolled separately.

28) What should be done if a family member dies?

Answer: The deceased member should be removed from the insurance policy by submitting a death certificate to the respective insurance office.

Reference Source:

• Health Insurance Act, 2074
• Health Insurance Regulation, 2075

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