Health Insurance Program of Nepal

Health Insurance Program of Nepal, under the insurance act was passed by the federal parliament on Tuesday 11th October, 2017 and was approved by Honorable president Bidhya Devi Bhandari on 18th October, 2017. In this article we present you some of the salient features of this  program as well as the act

Features of the health insurance program of Nepal
Picture How the health insurance system of Nepal is based upon 

Previously known as Social Health Security Insurance program lead by Social Health Security Development Committee, health insurance in Nepal first came into implementation from 2015 only. While other developed countries have been practicing it for over half a century, Nepal has finally leaped its step towards the implementation of the much needed program. 

The Health Insurance Act, 2017 is the sole document covering how health insurance systems are delivered across the country. This system is based upon the capitation method. The rates of service and drugs are formulated by the board setup according to the act.

Currently there are about 1183 medications and 1505 services provided for 1960 diseases  covered under the health insurance program of Nepal.

Who gets service according to the Health Insurance Act of Nepal? 

  • All Nepalese citizens 
  • Peoples wanting to get insured have to pay an annual amount of NRs. 2500 to the health insurance board (non refundable) for a family of five members. This is the minimum amount required for retrieving services of health insurance. That means if your family has five members, you are paying 500 rupees for each of your family members. 
  • Rs. 2500 is the minimum premium even if your family members are less than five. This means, you pay Rs. 625 if you have family members. Similarly, you pay, Rs. 834 if you have three members , Rs. 1250 for two members and Rs. 2500 if you are single. 
  • For each additional family members you shall pay Rs. 425 per member of the family. 
Health Insurance Program of Nepal
Picture courtesy of health insurance board of nepal 

Salient features of the health insurance act 

  1. The Act contains seven sections and 42 articles. 
  2. Section 3 of the act states that ‘parents and guardians are responsible for insuring the health of their newborn, children, senior citizens and persons with disabilities‘. Similarly, those ones at orphanages, old-age-homes and child reform centers need to have their health insured by their respective organizations. People who go for foreign employment should also involve their family in the program 
  3. Each family (of up to five members) is considered as a unit 
  4. Insurance Board setup as per article 13 of the act has 9 members (including one chairman and one member secretary). Out of them three are female (mandatory). Both the chairman and members should be the citizens of Nepal
  5. Qualification needed to be the chairman of insurance board: 
    1. should hold a bachelor’s degree 
    2. should have a work experience of seven years in related field 
  6. Qualification for member 
    1. For three nominated members, they must have a post-graduate degree in medicine, public health, economics or financial management 
    2. five years experience in related field 
  7. The tenure for executive directors is four years. S/he should have at least ten years of work experience in related field and should also have a master’s degree 
  8. The board is entitled complete rights to function as a person in the matter of financial expenses and various other rights 
  9. The financial reserve of health insurance board doesn’t  freeze  like other government organizations
  10. The board can make various directives as per this law

Services provided under the health insurance program of Nepal

This program provides 1505 services as already described. These services are be categorized as: 

  • OPD, IPD, Emergency Services, medicines 
  • Preventive services like immunizations, family planning, safe motherhood, nutrition
  • Yoga and psychiatric consultation
  • Diagnostic and rehabilitative services 
  • Ambulance services 

Some salient diagnostic services available freely to insurees

  • Radiological: USG (transabdominal and transvaginal), CT scan, MRI, ERCP, MRCP, HIDA scan, MUGA, colposcopy, hysteroscopy, DTPA, DMSA, FNAC (CT and USG guided), bronchoscopy, sigmoidoscopy, cystoscopy, colonoscopy, X-Ray, radiotherapy, brachytherapy, ABPM and much more 
  • Standard investigations: anti-TPO, iron profile, progesterone, growth hormone, creatinine clearance, TFT, vitamin D, vitamin B12, CA125, PSA, anti-CCP, LDH, ABG, anti DS-DNA
  • Abortion 

Services not available

  • Expensive spectacles, hearing aid 
  • Dentistry: Root canal treatment 
  • Cosmetic and Plastic  Surgery 
  • Artificial insemination  

How to leverage the benefit of health insurance 

  • You can be a member after signing up through FCHVs at your area. 
  • You must first go to primary point to take initial services, for referral to higher centres, even in the case of emergency.
  • It takes usually 2-3 months to start your insurance plan after signup.
  • You must renew yearly 

Health Insurance Service providers in Kathmandu Valley

Besides all primary health centres and district hospitals as well as regional hospitals of the insurance implemented districts, here are the institutions providing service in Kathmandu Valley 

  • National Trauma Centre, Mahaboudha, Kathmandu
  • Kanti Children Hospital, Maharajgunj, Kathmandu 
  • Shahid Gangalal National Health Center
  • Patan Mental Hospital, Lagankhel, Lalitpur
  • Human Organ Transplant Center, Bhaktapur 
  • Paropakar Maternity Hospital, Thapathali, Kathmandu
  • Bir Hospital, Mahaboudha, Kathmandu 
  • Patan Hospital, Lalitpur 
  • Manmohan Cardio thoraciac and vascular center, Maharajgunj, Kathmandu

Cons of the insurance system 

  • Takes a long time to initiate after you register 
  • no online registration and payment system 
  • Lack of co-operation to insurees in some insurance providers to the insurees 

Disclaimer and ending words about health insurance system of Nepal 

This is not the official site of health insurance board of Nepal. You can go to official site here. All services and medicines  have not been included in this page. If you want to know more information you can contact at 16600111224 (toll free) or +977-1-4100223. You can also mail your query at [email protected] 

health insurance program of nepal
these are the proposed amendments to the health insurance program 

2 responses to “Health Insurance Program of Nepal”

    • No, Teaching Hospital Maharajgunj doesn’t provide health insurance services. Teaching Hospital hasn’t enrolled itself with the health insurance program till date

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