Morung Express News
Kohima | June 4
The Gauhati High Court Kohima Bench (GHCKB), on June 4, directed Future Generali India Insurance Company Ltd (FGI) to finalise the settlement of pending health insurance claims under the Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) and Chief Minister’s Health Insurance Scheme (CMHIS) in Nagaland within four weeks.
The directive by the Division Bench comprising Justice Kekhato Sema and Justice Yarenjungla Longkumer was issued following the hearing of a Public Interest Litigation (PIL) concerning the withdrawal of services under the AB PMJAY-CMHIS schemes by empanelled private hospitals in Nagaland due to non-payment of dues.
During the hearing, the Court reviewed the minutes of a meeting held on May 7, chaired by the Joint Secretary, National Health Authority (NHA), and attended by representatives from the Insurance Regulatory and Development Authority of India (IRDAI), Department of Financial Services (DFS), the State Health Agency (SHA) Nagaland, and FGI.
The meeting highlighted serious concerns raised by the State over delayed payments during the policy period from April 1, 2024, to March 31, 2025, which led to private hospitals halting services from March 17, 2025.
FGI, in its defence, cited suspected fraudulent activities by certain empanelled hospitals for holding payments. However, the State clarified that dossiers of suspicious claims had already been submitted to a State Medical Committee for review. It was also noted that several flagged claims had previously been approved and paid, raising concerns about FGI’s due diligence.
The NHA reiterated that FGI is responsible for the actions of its empanelled Third Party Administrators (TPAs) and emphasised the urgency of releasing pending claims. IRDAI representatives stressed the importance of regulatory compliance, while DFS advised the State to examine penalty provisions for delayed settlements.
The meeting further clarified that the burden of proving fraud lies with the insurer and that claims cannot be rejected solely on procedural grounds such as missing documents or delays in submission.
FGI proposes case-by-case review
During the meeting, FGI proposed a case-by-case review with specific timelines. It committed to settling claims from hospitals outside Nagaland by May 15, and claims from hospitals within Nagaland (not flagged for fraud) by the same date. Alleged fraud cases were to be settled by May 30.
FGI also committed to deploying a team in Nagaland from May 16 to work with the Nagaland Health Protection Society (NHPS) and the State Medical Committee. It further assured that detailed data on pending and alleged fraud claims would be shared with the State.
In response, the State Government assured that any recoveries due to the insurer would be duly honoured. It also confirmed that strict action would be taken against hospitals found guilty of fraudulent activities, in line with NHA’s guidelines.
While the NHA called for coordinated efforts to restore services, it also scheduled a follow-up meeting for the first week of June to review progress.
However, the Court noted that FGI had failed to finalise the settlement process despite its commitments. Accordingly, the Bench directed FGI to conclude the process within four weeks from June 4 and file an affidavit confirming the same.
It also instructed that any dispute regarding the settlement must be resolved between NHPS and FGI, without affecting genuine claims raised by the Nagaland Private Doctors Association (NPDA).
The matter has been listed for further hearing on July 16.
It must be noted here that the Reliance General Insurance Company Limited (RGICL) has been appointed the insurer for AB PMJAY-CMHIS for the policy period from May 1, 2025, to April 30, 2026. The NHPS also floated a new tender recently for hospital empanelment under the scheme.
