Himachal Govt to Replace Himcare With AI-Powered Health Insurance Scheme Soon
Health insurance in Himachal Pradesh could soon shift to an AI-powered model as the government plans to replace Himcare.
Health insurance in Himachal Pradesh is set for a major overhaul with an AI-powered scheme proposed to replace Himcare.
Health Insurance: Himachal Pradesh is set to roll out a new artificial intelligence (AI)-driven health insurance scheme in November, replacing the existing Mukhya Mantri Himachal Health Care Scheme (Himcare), as the state government moves to overhaul its flagship health coverage programme amid allegations of financial irregularities.
Under the new scheme, eligible families in the state will receive free medical treatment coverage of up to ₹10 lakh, doubling the ₹5 lakh per family annual cover currently available under Himcare. The government has said the new model will “ensure transparency” and “help curb the possibility of corruption” in the processing of medical claims.
Health Insurance: AI to Flag Fraudulent Claims and Duplicate Bills
A central feature of the new scheme is the deployment of AI technology to scrutinise medical bills and claims submitted by hospitals. A technical analysis will be conducted on bills and records related to patient treatment, with the system designed to identify suspicious patterns, duplicate or unusual bills, fraudulent claims, and cases that do not align with the actual treatment provided.
Claims flagged by the AI system will undergo further investigation. The government has also put in place provisions to take action against hospitals or individuals found attempting to claim insurance payouts through fraudulent bills, with penalties and other punitive measures to be imposed once guilt is established.
The move to replace Himcare follows an announcement by chief minister Sukhvinder Singh Sukhu in March this year during the state legislative assembly’s budget session, when he cited “irregularities” in the existing scheme while announcing its transition to an insurance-based model. A vigilance inquiry into the matter has already been initiated.
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Health Insurance: Expanded Coverage: 280 Medicines and All Surgical Procedures
The Health Department has finalised the Standard Operating Procedure (SOP) for implementation of the new scheme, and preparations are underway to invite applications from insurance companies, with tenders expected to be floated this month.
The scope of treatment under the new scheme has been expanded to include 280 essential medicines, and provisions have been made to cover all types of surgical procedures under the insurance policy. The scheme also lays out mechanisms for beneficiary treatment, hospital empanelment, claim settlement, coverage of medicines and surgeries, and an overall monitoring framework. The government has said the objective is to provide cashless and improved healthcare facilities to eligible families while easing the burden of hospital expenses during serious illnesses or surgeries.
Health Insurance: Political Uproar Over Himcare’s Future
The transition has triggered political friction in the state. Himcare, launched in January 2019, currently provides eligible beneficiaries with cashless treatment coverage of up to ₹5 lakh per family per year at empanelled hospitals.
The Bharatiya Janata Party (BJP) had accused the state government of shutting down the scheme, an issue that led to an uproar in the recently concluded Monsoon Session of the Himachal Pradesh legislative assembly. Leader of opposition Jai Ram Thakur alleged that the Congress government was “strangulating” flagship health schemes, including Himcare.
Responding to the debate during the Monsoon Session, health minister Dhani Ram Shandil clarified that Himcare was a “useful scheme” and maintained that the government had no intention of discontinuing it.
