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LocalCircles’ Survey Reveals 43% Health Insurance Policyholders Faced Difficulties

Written by : Nikita Saha

May 6, 2024

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The report also found that a significant number of health insurance claims in India were either partially approved or outright rejected.

A recent study conducted by LocalCircles reveals that about 43% of health insurance policyholders encountered issues while processing their claims in the last three years.

The survey which involved more than 39,000 participants from 302 districts across the country, brought to light several problems such as denial of claims, partial payouts, and extended settlement periods.

The report also found that a significant number of health insurance claims in India were either partially approved or outright rejected.

"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% of health insurance policyholders who filed a claim in the last three years struggled with getting it processed," reported the survey.

Key Findings

According to the survey report, a significant 93% of the participants voiced the need for regulatory changes to address the prevalent issues in the health insurance sector.

Among the proposed changes is the requirement for insurance companies to disclose comprehensive data on claims and policy cancellations on their websites on a monthly basis.

The survey also revealed that in many instances, patients ready for discharge had to wait for an additional 10-12 hours because their health insurance claim was still being processed.

Moreover, if the processing was extended to the next day, the cost of the extra day’s hospital stay had to be borne by the patients themselves.

Additionally, the survey highlighted several major issues including the lack of complete disclosure about exclusions and eligibility for claims in their policies, the use of technical jargon and complex words leading to ambiguity in contracts, and claims being rejected due to pre-existing diseases.

Major Issues During Health Insurance Claims

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.

IRDAI’s Take

The majority of the people surveyed 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.

Previously, the IRDAI had acknowledged that one of the barriers to the spread of insurance across India is the lack of awareness about health insurance. To address this, they have implemented initiatives such as Bima Bemisaal to raise awareness about the importance of having a health insurance plan.

In a big move, recently the IRDAI omitted the age restriction on health insurance for individuals who are 65 years old and above. This move is aimed at enabling access for older individuals and enhancing coverage for high-risk health conditions.

LocalCircles is a social media platform that focuses on communities, governance, and urban daily life. It enables citizens to come together in communities or groups to raise issues, find trusted information, participate in policy, and engage in constructive collective action.

It conducts various surveys to understand the pulse of the community on different issues.


About Chime India

The College of Healthcare Information Management Executives (CHIME) is an executive organization dedicated to serving senior digital health leaders. CHIME includes more than 5,000 members in 56 countries and two US territories and partners with over 150 healthcare IT businesses and professional services firms. CHIME enables its members and business partners to collaborate, exchange ideas, develop professionally and advocate the effective use of information management to improve the health and care throughout the communities they serve. CHIME's members are chief information officers (CIOs), chief medical information officers (CMIOs), chief nursing information officers (CNIOs), chief innovation officers (CIOs), chief digital officers (CDOs), and other senior healthcare leaders. The CHIME India Chapter became the first international chapter outside North America in 2016 and is now a community of over 70+ members in India. For more information, please visit www.chimecentral.org

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