Health insurance in Nepal Everything You Need To Know

Last Updated on September 25, 2024

The Government of Nepal had launched health insurance in Nepal in the fiscal year 2016/17 from the three districts: Kailali, Baglung, and Ilam, but, now it has covered most of the districts or across the country.

Public health insurance is not compulsory, people can enter on a voluntary basis and can benefit from insurance coverage In the case of an insured or family member suffering from any kind of illness.

What is health insurance in Nepal?

It is an insurance that covers an individual’s health expenses entirely or partially as a result of sickness or injury. Any Nepalese citizen between the ages of 16 and 65 can buy a health insurance plan covering their own and family member’s medical expenses.

What are the benefits of Health insurance in Nepal?

The main benefit of medical insurance in Nepal is to cover the medical expenses of the dreaded diseases and financial protection from an unexpected situation. The insured receives the following benefits;

• Pay for the cost of own treatment
• Pay for the cost of treatments for family members.

How many types of Medical health insurance are in Nepal?

There are two types of medical insurance in Nepal that are as follows;

• The government provided (Social health insurance)
• Provided by private institutions

Social health insurance: Social health security is a social protection program of the government of Nepal which allows its citizens to access the quality health care services without imposing the financial burden on them.

Nepalese people can buy an insurance plan for one year by paying a small amount of premium Rs. 2500-3500 and seek care for specified illnesses in government hospitals without a cost.

Private Health insurance: Private insurance companies also provide medical insurance to the people and the insured will seek treatment in a private or non-governmental hospital.

All you need to know about Nepal’s health insurance;

1. There are two types of health insurance in Nepal public and private.
2. Public health insurance is provided by the government of Nepal.
3. Privates health insurance is provided by private insurance companies.
4. If you have made medical insurance through the government of Nepal, you should only seek treatment in a government hospital.
5. People who have purchased insurance from a private company will go to private hospitals or medical clinics for treatment.
6. The insurance applies only to the costs of the diseases, listed in the policies.
7. Public insurance does not accept foreign treatment.
8. Some private insurance companies cover the cost of medical treatment in India.
9. If you have signed up for private health insurance in Nepal, you may be required to pay your medical expenses first and claim with the company later.
10. If you purchase medicine from the pharmacy and clinic without a doctor’s recommendation, you will not be entitled to claim insurance.
11. Insurance companies pay you, including; doctor’s fees, ward charges for a number of days.
12. Although some privates insurance companies provide you cashless services especially in Kathmandu, most of the places you should pay your money and claim back to the insurance provider.
13. There are various terms and conditions to be applied.
14. Your insurance applies to your family member between the ages of 1 and 70yers.
15. Only allow for you to have the following as the beneficiary of your insurance packages;

    • Children age less than 18yrs old.

    • Parents age less than 70yrs old.

16. Your insurance does not cover your sibling (brothers and sisters).
17. If you have missed any necessary documents, you can not claim that amount with the private insurance company.
18. You can only insure 5 family members additional members will cost extra.
19. It’s been listening in the government hospital patient had to wait a long time, even a week, to see the doctor. 
20. Some claim that the private insurance company’s pay ratio is less than the government.

PROCEDURES FOR  HOSPITALIZATION/ MEDICAL CLAIMS

You do not need to pay anything to treat yourself in a government hospital if you have signed up for a public health insurance scheme. For private insurance, you should claim later to the insurance company that you paid for treatment. The documents required are as follows;

1. Claim form duly completed (provided by the Company)
2. Complete Hospital/Doctor papers
3. Discharge Summary Sheet in case of hospitalization
4. Medical Prescriptions and Bills in original
5. Pathology Reports, if any
6. X-Ray, USG, CT Scan, MRI, etc. Reports, if any

It is very important to ensure that the above documents have been submitted in order to settle your claim from the private health insurance provider-expeditiously, otherwise the claims process may be delayed.

When you submit your claim to the private insurance company they will study, confirm the details and decide on a claim that complies with the relevant condition of the policy in all respects, then only the fund will disburse and pay to you.

Private Health insurance companies in Nepal.

1. Medlife Nepal
2. Siddhartha Insurance
3. Premier health insurance
4. IME general insurance
5. Shikhar Insurance Company Limited
6. Sanima General Insurance Company Limited
7. Prudential Insurance Company Limited

Conclusion;

Although both government and private insurance companies offer health insurance in Nepal, there is still a lot of public hesitation about getting into it because of a lack of expedited treatment in government hospitals and a slow process for paying the claimed amount by private insurance companies. This initiative is not fundamentally bad in Nepal, but it needs to be reformed.