In a recent submission to the Rajya Sabha, the Ministry of Finance revealed that more than 89 lakh health insurance claims remained pending across India over the last five financial years, with total outstanding claim amounts exceeding ₹29,689 crore.
Responding to an unstarred question by MP Smt. Renuka Chowdhury, Minister of State for Finance Shri Pankaj Chaudhary shared extensive data on health insurance claim settlements. According to the Insurance Regulatory and Development Authority of India (IRDAI), from FY 2019-20 to FY 2023-24, insurance providers settled over 10.3 crore health claims amounting to ₹3.07 lakh crore. However, approximately 20.7 lakh claims worth ₹7,584 crore were still pending as of March 31, 2024.
Cashless Claims Gain Momentum
The Minister noted a growing trend toward cashless transactions in healthcare. During FY 2023-24, 58.39% of claims were settled through the cashless mode in terms of count, representing 66.16% of the total amount disbursed. This shift is expected to ease the burden on policyholders and reduce delays in reimbursements.
National Health Claims Exchange Expansion
As of March 28, 2025, only 450 hospitals have been onboarded to the National Health Claims Exchange (NHCX), a digital platform aimed at standardizing and streamlining health insurance claims processing. The government emphasized ongoing efforts to expand hospital participation in the exchange to improve accessibility and reduce processing delays.
Policy Reforms to Strengthen Accountability
To address concerns over claim delays and rejections, IRDAI has implemented a revamped regulatory framework through its Master Circular on Health Insurance (issued on May 29, 2024) and Insurance Products Regulations (March 2024). Key reforms include:
- Mandatory issuance of a Customer Information Sheet (CIS) outlining coverage, exclusions, and sub-limits.
- Specific timelines: Cashless authorization must be decided within 1 hour; final authorization within 3 hours of discharge request.
- Claims cannot be rejected without approval from the Product Management Committee (PMC) or the Claims Review Committee (CRC).
- Insurers must provide written explanations for claim rejections and respond to grievances within 14 days.
- Establishment of Grievance Redressal Officers in every office and dedicated committees to oversee complaints and monitor claims processing.
- Enhanced grievance tracking through the Bima Bharosa portal.
- Binding enforcement of decisions by the Insurance Ombudsman, with insurers liable for penalties of ₹5,000 per day for delays.
A Push for Better Consumer Protection
These regulatory changes reflect a broader push by IRDAI to make the health insurance sector more consumer-centric. With increasing enrollment in health insurance schemes and a digital push through NHCX, the government aims to reduce pending claims, improve processing efficiency, and build greater trust in the system.
As the healthcare landscape evolves in post-pandemic India, ensuring timely, transparent, and fair claim settlement remains a critical priority.
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