May 30, 2024

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Health Insurance Claim: 43% policyholders faced difficulties, some had to wait an extra day at hospital, survey

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Many health insurance claims in India have either been rejected or approved partially in the last three years, according to a recent survey by Local Circles. This conclusion was reached after taking inputs from 39,000 people in the 302 districts of India.

“Many policyholders cited their experience of getting a health insurance claim processed. Challenges faced ranged from insurance companies rejecting claims by classifying a health condition as a pre-existing condition to only approving a partial amount. 43% health insurance policyholders who filed a claim in the last three years struggled with getting it processed,” reported the survey.

What are the major issues faced during claims by health insurance policyholders in India?

As per the survey report, some of the major issues faced by health insurance 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

What are the on-ground experiences of people making health insurance claims?

People, who have health insurance and filed a claim, voiced their experience to the survey researchers. It was found that health insurance companies are processing claims with such delay that the discharge from the hospital is getting delayed.

According to the survey report, “In several cases cited by policyholders on LocalCircles, it took 10-12 hours after the patient was ready for discharge for them to get discharged because the health insurance claim was still getting processed. If they stay back at the hospital another day to do so, the cost of that additional night’s stay has to be borne by them. And according to several patients, this is the experience where the insurance company has already provided a pre-approval to the hospital’s TPA desk before admission of the patient.”

What the policyholders expect from the insurance regulator

The majority of the people whose opinions were recorded in the survey said that they wanted the insurance regulator-Insurance Regulatory and Development Authority of India (IRDAI) to mandate insurance companies to publish certain details each month.”Taking into account the difficulty faced in getting insurance claims processed, 93% of respondents indicated 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. People believe that such a disclosure will improve the transparency of reporting and discourage insurance companies from not cancelling policies arbitrarily,” as per the survey report.As per the survey report the people 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.


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