May 30, 2024

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Health insurance: 43% of policyholders faced struggles to get claims after treatment, states survey

2 min read

Almost four out of 10 patients faced hurdles to get their health insurance claim. As per a survey, 43% of health insurance policyholders, who filed a claim in the last 3 years, struggled to get the money or settle payment dues at a hospital after treatment. 

The survey by LocalCircles stated that general insurance policy owners struggled the most in getting health insurance claims processed compared to motor or other insurance policies. 

The policyholders noted that challenges they face include rejection of claims, partial amount approvals, and longer time to settle hospital bills.

The survey noted that six major issues faced by policyholders include lack of full disclosure about exclusions and eligibility for claims in their policies; ambiguity in contracts due to the use of technical jargon and complex words; claims rejected due to pre-existing disease; eligibility other than the preexisting disease and crop insurance rules tied to the scheme.

Besides this, one of the top issues that consumers have been regularly reporting is that of rejection of health insurance claims including cancellation of policies by insurance companies. 

Explaining further, policyholders said they faced challenges like insurance companies rejecting claims by classifying a health condition as a pre-existing condition to only approving a partial amount.

They noted that the process of claiming health insurance is extremely time-consuming with many policyholders and their family members literally spending the last day of their hospital admission running around trying to get their claim processed. 

The insurance claimants said in several cases, it took 10-12 hours after the patient was ready for discharge for them to actually get discharged because the health insurance claim was still getting processed. 

They noted that if they decide to stay back at the hospital for another day, the cost of that additional night’s stay has to be borne by the policyholder and not by the insurance company. 

Talking about solutions, 93% of insurance holders said that they are in favour of IRDAI making it mandatory for insurance companies to disclose details of claims received, rejected, and also data about policies approved and policies cancelled on their websites each month.

As per the survey, the policholders also want the IRDAI, Health Ministry as well as the Consumer Affairs Ministry to collaborate to ensure health insurance claims are processed fairly and fast and should not lead to harassment of the policyholder.

Earlier this year, the Department of Consumer Affairs informed the Ministry of Finance that owing to the rising number of complaints of mis-selling of insurance policies, rules should be changed to ensure that insurance agents maintain an audio-visual record of their sales pitch. This is to ensure that prospective buyers are made aware of all policy features and not just the positive points. 

IRDAI was reportedly in discussion for more accountability by all parties, which would include an appropriate framework to conduct an audit of the solicitation process, customer outcomes, and redressal mechanisms.


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