Surge in Health Insurance Complaints :Every Policy Holder needs to know..

Steep surge in Health Insurance-related Complaints:

Health insurance is meant to be a financial support when you encounter any health emergencies or any planned hospitalizations. In recent years, policyholders are facing lots of challanges while getting claims approval and this has rasied the alarm beacuse there is a steep surge in health insurance-related complaints. From claim delays to unexplained deductions or upfront rejections citing policy terms and conditions.Policy Holders are increasingly getting frustrated.

You or your near and dear might have encountered either their claim/cashless has been reejcted or if approved then approved amount is lesser or paid lesser than the Hopsital total Bills.Do you know why it happnes ? couple of reasons are :

• Rapid Growth in Health Insurance Buying

• Rising Claim Volume

• Rising Health Care Cost

• Policy Wordings

• Misselings and Policy Awareness

• Strickter Fraud Mechanisim

Why Health Insuarance Complaints are Rising?

The core problem of this is the rapid growth of Health Insurance penetration in India ,especially post pendamic, which brought corresponding surge in claim.Higher the claim more frictions and higher probablity of complaints.

Rising Health Care Cost:

Healthcare cost in India is growing faster than general inflation.Very frequently Hospitals revise room rent, treatment charges, and consumable costs.Now entire cost if Room Tarrif dependent . As hopspita bills go up, insurance companies scrutinize claims more strictly to manage their financial exposer, leading to more queris , Rejection,Partial Approvals or push for Reimbursement options

Rapid growth in Health Insuarnce Buying:

Pendemic exprience forced people think to buy health insurance and that spiked the growith of Health Insurance penetration.Leading to misselinga nd more uses of claim and that further resulted in unhappy claim experience and dissatisfaction among policy holders.

According to reports, the Insurance Regulatory and Development Authority of India (IRDAI) has recorded a sharp uptick in complaints related to health insurance, with figures climbing steadily over the past few years. This surge can be attributed to various factors, including the increasing complexity of policy terms, lack of clear communication, and dissatisfaction with claim settlement processes. Policyholders often find themselves navigating a convoluted system, leading to confusion and frustration when expectations are not met during the time of need.

Rising Claim Volume:

Pendamic forced people to visit Hopsital of Dr even on small health issues , resulted in hospitalization which was never expected and with increase in volume Insuarcne companies also started looking very minutely and that led to rejection of claims on ground "hospitalization was not need, can be trated on OPD" .

Policy Wordings:

With rise in buying people were not well versed with policy terms and conditions , only they know health insurance policy is there , every thing will be taken care. However every policy has certaoin terms and conditions so same was here as well.Terms like , Waiting Period, Pre- Existing Diseases, Exclusions, Sub-Limits, Co-Pay and many more which resulted is rejection or delayed claim approval.

Stricter Fraud Detection Mechanisms:

Insurers today use advanced analytics to detect fraud. While this helps reduce fraudulent claims, it also increases the number of genuine claims kept on hold for verification, triggering more customer frustration and dissatisfaction.

Lack of Policy Awareness:

A significant % of claim get rejected/ grievance registered due to people are unaware of policy details

• Waiting Periods

• Non payable Items

• Network Hospital Terms

• Room Rent Restriction

• Pre Approvals/Intimation for Hospitalization

When claims are denied on these grounds, policyholders feel cheated—even though these terms were part of the policy document.

Every Policy Holders should be aware of why Claim get rejected:

The leading causes behind the surge in complaints, based on industry trends and customers behaviour

Claim Denials:

This is the most painful and common complaint. Claims are denied mainly because of:

• Non-disclosure of pre-existing diseases

• Treatment falling under exclusions

• Diagnosis not matching the claim request

• Fraud suspicion

• Lapsed or inactive policy

A denial hits hardest when it comes unexpectedly during hospitalization.

Claim Delays:

Even if your claim is valid, you may face delays due to:

• Insurer asking for repeated documents

• Hospital not responding to insurer queries

• TPA coordination gaps

• Lack of medical justification

• High claim volume during peak seasons

Delays cause stress, especially during cashless treatments where hospitals may push for security deposits.

Deduction of Claim Amount:

Many customers get a shock when the insurer approves less than expected. Common deduction reasons:

• Room rent capping impacting all other charges

• Non-payable consumables (gloves, PPE kits, syringes, etc.)

• High doctor fee beyond the policy’s “reasonable charges” limit

• Treatment cost exceeding standard rates in that city

Unfortunately, customers often aren’t informed upfront about these limitations.

Cashless Denial at the Last Minute:

Hospitals may suddenly say, “Cashless not approved,” even after pre-authorization. Reasons include:

• Suspicion on hospitalization justification

• Policy waiting periods

• Sub-limit exhaustion

• Non-network hospital issues

This leads to panic, especially during emergencies.

Poor Customer Support:

Many customers complain about:

• Long waiting time

• Generic, scripted responses

• No clear updates on the claim status

• Difficulty escalating issues

Delayed communication leaves policyholders confused and helpless.

Wht to do to Avoid Claim Problems?

Understand Your Policy Clearly:

Before buying or renewing, read about:

• Waiting periods

• Sub-limits

• Exclusions

• Room rent limits

• Daycare coverage

• Network hospitals

A 30-minute review can save you thousands during claims.

Keep Medical Records Organized:

Insurers verify everything. Keep:

• First Consultation Papers

• Dr.Prescriptions

• Diagnostic reports

• Admission and discharge summary

• Bills and receipts

Missing documents are one of the biggest reasons for delays.

Inform Insurer Immediately:

For planned hospitalization, inform the insurer at least 48 hours prior.For emergencies, inform within 24 hours.

Late intimation is a common reason for claim complications.

Avoid Non-Disclosures:

Many claim issues arise because customers hide:

• Previous hospitalizations

• Ongoing medication

• Chronic illnesses

Be transparent—it increases your claim approval chances.

Choose Room Category Wisely:

Policy Sum Insured/Assued is your money,even a slight upgrade of room category can increase your total bill and reduce insurer payout due to proportionate deductions. Always choose a room within your eligible limit.

Use Network Hospitals Whenever Possible:

Cashless approvals are faster and smoother in network hospitals.Reimbursement claims take longer and have higher scrutiny hence use network hospital always .

Don’t Ignore Policy Renewal Dates:

A single day of missed payment can make your policy lapse. Even if restored later, any illness during the break may be treated as pre-existing, affecting future claims.

Knowing your rights and responsibilities can greatly reduce the chances of disputes.

Claims360 is here to help you if still face any cocnern related to your Claims.

Email:-care@claims360.in

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