Health Insurance Board Appeal Against Test Misuse
28th January 2026, Kathmandu
Nepal’s Health Insurance Board has issued a high-priority public appeal aimed at preserving the long term viability of the National Health Insurance Program. Under the strategic slogan “Use Health Insurance Responsibly,” the board is calling on insured citizens and healthcare providers to eliminate the culture of unnecessary medical testing and fraudulent claims. As of January 2026, the program has become a vital safety net for millions of Nepalis, but it faces a severe financial crunch due to a combination of budget exhaustion, massive payment backlogs to hospitals, and a rising trend of service misuse.
Health Insurance Board Appeal
According to recent data, the Health Insurance Board (HIB) currently protects approximately 50,000 citizens every single day, preventing out-of-pocket health expenditures that average nearly Rs 80 million daily. However, the system is struggling under a total outstanding debt of approximately Rs 12.5 billion owed to over 500 health facilities across the country. This financial strain has led to several major institutions, including the Tribhuvan University Teaching Hospital (TUTH), temporarily suspending insurance-based services, leaving thousands of vulnerable patients without care.
Addressing the Crisis of Unnecessary Medical Tests
One of the primary drivers of the board’s appeal is the prevalence of “moral hazard”—a situation where insured individuals demand medical services simply because they are “free” or covered by the state. The board has noted a concerning trend where patients pressure doctors to prescribe expensive diagnostic tests, such as MRIs, CT scans, and complex blood panels, even when there is no clinical justification.
Executive Director of the Health Insurance Board, Bikesh Malla, recently highlighted that nearly 8 to 10 percent of all health check-ups conducted under the scheme are medically unnecessary. This “diagnostic inflation” not only wastes precious medical supplies and manpower but also depletes the insurance fund that should be reserved for life-saving surgeries and chronic disease management.
Key Directives for Insured Citizens:
Trust Clinical Judgment: Patients are urged to rely on their physician’s diagnosis rather than demanding specific lab tests.
Protect the Fund: The insurance cap of Rs 100,000 (which increases for senior citizens and critical illnesses) is a collective resource. Depleting it on minor issues limits the board’s ability to pay for major medical emergencies.
Ethical Participation: The board has implemented a 10 percent co-payment system at many private and tertiary hospitals to discourage casual use of high-end services.
The Role of Health Service Providers in Sustainability
The appeal is not directed solely at patients; hospitals and diagnostic centers are also under scrutiny. The Health Minister, Dr. Sudha Sharma Gautam, recently pointed out that some service providers have been found charging for services with improper intent, leading to a 20 percent rejection rate of all claims submitted to the board.
To combat this, the board has issued a strict 19-point action plan for hospitals:
Advertisement
Internal Review Committees: Every participating hospital must form a committee to cross-check claim files before submission to ensure they meet the board’s criteria.
Prescription Accuracy: Claims will be rejected if the Nepal Medical Council registration number of the prescribing doctor is missing or if medicines are dispensed without a valid prescription.
Ethical Billing: Hospitals are warned against encouraging patients to undergo extra tests just to exhaust their insurance premiums.
Navigating Payment Delays and Service Disruptions
The timing of this appeal is critical, as the health insurance program is currently at a crossroads. The government recently allocated Rs 10 billion for the 2082/83 fiscal year, but that amount was almost entirely consumed by clearing old dues from the previous year. This “vicious cycle” of debt has caused friction between the board and major state-run hospitals like Bir Hospital and TUTH.
While the Ministry of Health is currently seeking an additional Rs 1 billion from the Ministry of Finance to keep TUTH operational, the board maintains that systemic reform is the only permanent solution. This includes a transition to biometric identification for beneficiaries and real-time SMS notifications of expenses to prevent fraudulent billing by third parties.
A Collective Responsibility for the Future
Nepal’s health insurance program is a constitutional right aimed at achieving Universal Health Coverage (UHC). However, as the board emphasizes, a right also carries a responsibility. For the program to survive, it must transition from a “spending” model to a “care” model. This means focusing on preventive health and essential treatments rather than high-volume, low-value diagnostic testing.
The board’s appeal serves as a reminder that the insurance fund belongs to the people. When a citizen uses the service responsibly, they are ensuring that a neighbor in critical need can receive life-saving treatment tomorrow.
Conclusion
The Health Insurance Board Appeal is a call for a national culture shift in healthcare consumption. By respecting medical necessity and following the board’s new guidelines, both patients and providers can help rescue the program from its current financial crisis. The sustainability of Nepal’s most successful social security initiative depends on this collective discipline.
For More: Health Insurance Board Appeal
