KATHMANDU, Feb 3: The Health Insurance Board (HIB) has decided to limit outpatient health services to Rs 25,000 per family per year, a move that has raised concerns among insured citizens and health experts.
According to a decision made by the board meeting held on January 8, the outpatient service allocation under the benefit package will now be capped at Rs 25,000 per family of five, equivalent to Rs 5,000 per member annually. The board has issued a public notice stating that the decision will come into effect from February 13.
However, the HIB has clarified that coverage for eight categories of critical illnesses will remain unchanged. Under the existing provision, insured individuals suffering from these serious diseases will continue to receive up to Rs 200,000 per person per year.
The board stated that the revised ceiling aims to reduce its financial burden and ensure more effective utilization of insurance services. It further noted that insured patients must be admitted to hospital wards to access additional benefits beyond outpatient services. Under this arrangement, patients who are hospitalized will be eligible to use the remaining Rs 75,000 of the annual coverage.
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Health Insurance Board Information Officer Bikesh Malla said the decision was taken to manage the ongoing financial strain faced by the insurance system. He maintained that the benefit package itself has not been reduced, as insured individuals can still use the remaining amount in cases of emergency care or hospital admission.
“The main objective is to ensure proper use of insurance services and manage the current financial crisis,” Malla said, adding that the policy could be revised if the insurance fund improves in the future.
The HIB had previously urged hospitals and insured individuals to avoid unnecessary medical tests. Due to mounting payment liabilities and delays in claim settlements, several major hospitals in the Kathmandu Valley have already suspended health insurance services. The HIB said it is making efforts to address the financial crisis.
However, former Health Insurance Board director Dr Senendra Raj Upreti warned that the decision contradicts previous agreements and could negatively affect insured citizens. Under earlier arrangements, insured individuals were entitled to health services worth up to Rs 100,000 per year, regardless of whether the services were inpatient or outpatient.
“The new decision increases the risk of existing insured members discontinuing the programme,” Upreti said, “Such a provision might have been acceptable for new enrollees, but it could discourage long-term participants.”
Upreti also said the policy would particularly affect patients with chronic illnesses who require regular outpatient treatment without hospital admission, arguing that it runs counter to the objective of improving access to healthcare.
Public health expert Dr Sharad Onta also criticised the board’s decision, calling it inconsistent with the core principles of health insurance. He said that healthcare needs are unpredictable and that limiting outpatient services could deprive patients of necessary treatment.
“Many chronic patients depend solely on outpatient services, and restricting this to Rs 25,000 annually could compromise their right to healthcare,” Onta said. He said that the Rs 75,000 available through hospital admission does not fully compensate for the earlier Rs 100,000 entitlement.
He further said that implementing such a rule without strengthening basic healthcare services could create confusion among insured citizens and undermine confidence in the insurance programme.
