How Health Insurance Claims Work in Nepal: Cashless, Reimbursement and Government Schemes

Most arguments about health insurance claims in Nepal are not really about the insurance. They are about a claim form signed by the wrong person, a discharge summary that arrived without a doctor's signature, or an itemised bill filed after the window had closed. The policy was fine. The file was the problem.

What follows is about private insurers and the third-party administrators, or TPAs, who run claims desks for many of them. Government and social health insurance works differently, with its own forms, its own counter and its own grievance route, so it gets a section of its own further down. Blending the two paths produces a document list that fits neither.

Who does what when you claim

Several hands touch a claim. The hospital treats you and prepares the clinical documents. Your insurer carries the risk and makes the final decision. A TPA is a company the insurer appoints to run the claims desk: it receives pre-authorisation requests, checks documents and coordinates with the hospital. And you, or someone in your family, are the one making sure the file is complete and that the insurer has your current contact and bank details.

Your policy schedule tells you whether you deal with the insurer directly or through a TPA. That matters, because the request goes where the schedule says, not where a friend's experience says.

Cashless and reimbursement: how each route works

Cashless hospitalisation only works inside the insurer's network. A network hospital is one the insurer has an agreement with, and the hospital and insurer settle the bill between themselves. You pay whatever the policy says is yours: a deductible if there is one, the cost of items the plan leaves out, an upgrade beyond the room category the plan allows. The catch is that word network. A hospital on one insurer's list can be missing from another's, and lists change as agreements are signed and dropped.

So confirm the list before you go in, not after. Your insurer's or TPA's own website, app or claims desk is the source. A laminated sheet at a hospital reception desk, or a friend's experience from two years ago, is not. Ask in writing and keep the reply.

Reimbursement works differently, at least in concept. You pay the hospital yourself and file afterwards, and the insurer pays back what the policy allows. The bill is settled by you first and argued about later, which is why receipts and the itemised bill carry so much weight on this route. Anything you cannot show a receipt for is hard to recover.

One point that applies to both routes. Plans commonly tie what they pay to a room category or a treatment package rather than to whatever the final bill happens to say, so the gap you end up filling yourself tends to grow the further you move up from what your plan covers. Read that part of the wording before you choose a room, not after.

Pre-authorisation: what it is and what it is not

Pre-authorisation is the insurer or TPA confirming, before or shortly after admission, that the treatment falls within the policy, and stating roughly how much they will cover. Usually the hospital's billing desk sends the request with your policy details. Planned admissions are normally built around it. Emergencies get handled after the fact.

Here is the part people get wrong. Pre-authorisation is not a final approved amount, and it is not a promise that the claim will be paid. It is a decision based on the information sent at that moment. If the diagnosis changes, or the hospital bills for something outside the original request, the final settlement can still be reduced.

Requirements, time windows and the rules for planned versus emergency treatment differ from plan to plan. No single rule applies across Nepali insurers. Read your own policy wording and the instruction page your insurer or TPA publishes.

The paperwork you assemble

Instead of a generic list that will not match your insurer, think about what each piece of paper does. Every claim file answers a few questions: who you are, what was wrong, what was done, what it cost, and whether the bill has actually been paid.

• Identity and policy proof: policy number, citizenship or passport copy, and for dependants the document showing the relationship.
• Clinical documents: admission notes, discharge summary, investigation reports, prescriptions. These come from the hospital, and their dates should line up with the dates on the bill.
• The billing set: itemised hospital bill, receipts, plus pharmacy or lab bills that sat outside the hospital package.
• The claim form: the one published by your insurer or TPA, signed wherever it asks for a signature.
• Payment details: the bank account the settlement should reach, in the name the insurer expects.

Your insurer's or TPA's own claim form is the authority. It states what it wants, in what format and by when. Download it from their own site rather than working from a photocopy at a hospital counter, because forms get revised and old versions come back rejected.

The deadline after discharge

This is where a lot of otherwise clean reimbursement claims die. The clock usually runs from the date of discharge, not from the day someone finally handed you the bills, and the window in the wording can be shorter than people expect. There is no national number to quote here and no standard window across companies, so read the deadline in your own policy wording and again on the claim form itself. If something has slowed you down, a readmission, a death in the family, write to the insurer or TPA before the deadline passes and ask for an extension. Get the answer in writing. A documented request that arrived on time is a far better position than a perfect file that arrived late.

How long a decision takes

Your policy wording, or your insurer's own service page, may state a turnaround time for a pre-authorisation decision and for settlement once a complete file is in. Where a company publishes a number, that number belongs to that company. It is not an industry standard and it is not a guarantee for your claim. Check the wording and the service page of the insurer or TPA you actually bought from. If a decision runs past the stated time, ask for your file's reference number and follow up in writing, so there is a dated record of the delay.

Government and social health insurance runs on a separate track

If your treatment was covered under a government or social health insurance scheme rather than a private policy, almost everything above stops applying. The scheme does not use a private insurer's claim form, it does not route requests through a TPA, and it does not share a complaints desk with private companies. It has its own enrolment record, its own card, its own designated hospitals and its own office counter.

Practically, that means you start from the scheme's own office or portal, not from a private insurer's helpline. The first thing to check is your enrolment. Is it current? Do the details on the card match your citizenship certificate or national ID exactly, spelling included? A mismatch between the name on the card and the name on the hospital file is a common reason a case sits still at the counter while everyone waits for someone else to fix it.

The second thing is where you are allowed to be treated. Scheme treatment usually has to happen at a facility that participates in the scheme, and a move from one level of care to another often has to be referred and documented before the higher-level treatment is covered. That part catches people out. Go straight to a bigger hospital without the referral step and you can end up outside the covered path even though the illness and the treatment were both covered in principle. Ask the scheme office how referral works in your situation before you travel, not after.

Tell the hospital at admission that you are using the scheme. Scheme paperwork usually starts at the counter while you are being admitted, and it is far harder to reconstruct afterwards than to fill in on the spot. Keep the card with you, and keep every discharge document and receipt the scheme asks for.

One more thing worth understanding about the scheme: what it is not. It is not a wallet you can spend at any hospital you like, and it is not a quiet top-up that covers the parts a private policy leaves out. It applies where it applies, at participating facilities, for the services it lists, under its own rules. Treating it as a general entitlement that follows you anywhere is the quickest route to a bill you did not plan for. Benefit packages and covered services do get revised from time to time as well, so what a neighbour received last year is a poor guide to what you will get this year.

On the office itself, expect some confusion. The body that runs this kind of scheme has been renamed, restructured and shifted between offices more than once over the years, sometimes sitting closer to the health ministry and sometimes elsewhere in government. That is why the office named in an old news report, or in a relative's memory of how it worked five years ago, may no longer be the one handling your case. Confirm the current name, the current forms and the current grievance route through the health ministry's own website, or through the office printed on your own enrolment card. A forwarded screenshot is not a reliable source, and neither is a phone number saved in someone else's contacts.

Grievances follow the same logic. A scheme dispute does not go to the insurance regulator that oversees private insurers. It goes through the scheme's own complaint steps, and if it climbs further, through the ministry's channels. Mixing the two routes is how people end up filing the same complaint twice and getting nowhere with either.

If you hold both a private policy and a scheme entitlement, do not put them in one file. Ask each office separately how it treats the other. Some coordinate; others expect you to claim from one first and show what is left to the other, and the order can change what you get back. Get that answer in writing before you file with either.

Exclusions, and the clauses behind rejections

The excluded conditions, waiting periods and sub-limits are written into each policy wording, and they differ from plan to plan. What follows is a list of clause types rather than a national rulebook.

• Waiting periods, which often run differently for a new policy, a pre-existing condition and a specific listed condition.
• Pre-existing conditions, as defined in the wording, sometimes with a lookback period.
• Sub-limits and room-rent caps, which usually reduce a bill rather than reject it outright.
• Non-disclosure at the proposal stage, which can void a claim rather than trim it.
• Treatment outside the network, or treatment the policy classifies as elective or cosmetic.
• Documents missing from the file, or sent after the deadline named in the wording.

When a health insurance claim is rejected, ask for the specific clause the insurer relied on, in writing. If the notice does not name one, that is the first thing to chase.

Appeals: getting the reason, then asking for a review

Ask for the rejection in writing, with the policy clause referred to. Keep the acknowledgement, the reference number and the dates of every exchange. If the decision rests on a wrong fact, a date or a diagnosis code, write to the insurer's or TPA's grievance officer asking for reconsideration and attach the corrected document. Preserve the whole file: discharge summary, itemised bill, receipts, prescriptions and the original claim form.

If that does not settle it, complaints about a private insurer go to the insurance regulator, the body that supervises insurance companies in Nepal. Reach the complaints procedure through that regulator's own official website and follow the published steps exactly as they are listed there, because both the steps and the online forms have changed before. The regulator itself has gone under a different name in the past, which is why older pages and older relatives may call it something else. Find it through the official site rather than through a search result that merely looks right. This section is procedural information, not legal or financial advice.

Keep everything in one place

Photograph each document before you hand it over. Save the claim reference number in your phone. If two people are dealing with the hospital and the insurer, agree on who holds the file. Before assuming the insurer is being difficult, check whether a page is simply missing.

None of this makes a claim painless. It just removes the reasons a decent claim gets delayed, and those reasons are almost always clerical rather than medical or legal.

This article is general information. Terms are set by each policy, by each scheme and by the regulator, and nothing here guarantees or predicts the outcome of any claim. Confirm details with your insurer, your TPA, the scheme office or the regulator before relying on them.

Last reviewed: September 2026. Nothing here quotes any policy wording, and no figure, deadline or procedure described above overrides the documents you were actually issued.