Complaints against health insurance claims in the 11 months of the current fiscal year have surpassed numbers of full FY25 by 14.5 per cent and around 55 per cent of FY24, data presented by the Finance Ministry in Lok Sabha on Monday showed.
“A total of 47,658 complaints during FY 2023-24, 64,365 complaints during FY 2024-25 and 73,729 complaints during FY 2025-26 up to February 2026, pertaining to various reasons in health insurance claims were registered on the ‘Bima Bharosa’ portal,” Minister of State in the Finance Pankaj Chaudhary said in a written reply. It may be noted that, post Covid, the premium for health insurance in many cases has more than doubled, while complaints about claim rejections are rising at an alarming rate.
Mandatory Specifics
Meanwhile, according to Chaudhary, Insurance Regulatory and Development Authority of India (IRDAI) has informed that Insurers are mandated to communicate specific reasons for rejection to the claimant, with reference to the relevant policy terms and conditions.
It is also stipulated that no claim shall be repudiated without the approval of the Product Management Committee (PMC) or its three-member sub-group, the Claims Review Committee (CRC) of the insurer.
“Among other reasons, claims may be rejected due to exclusion clauses and conditions in the policy, including cases where hospitalization is not required and the treatment falls under out-patient (OPD) services,” he said. Further, with regard to complaints, it is submitted that there is no specific categorization capturing instances of rejection of hospitalization claims on the ground that the treatment has been categorized as an out-patient service.
Proper Governance
According to the Minister, IRDAI has informed that health insurance policy terms and conditions only provide for criteria for admissibility of medical expenses incurred by the policyholder under the policy. He also informed that the regulator has introduced several measures to bring in transparency, and fairness in the health insurance claims settlement processes.
“In case of repudiation, rejection, or partial disallowance, the insurer shall communicate detailed reasons with reference to specific policy terms. Aggrieved claimants may approach the insurer’s Grievance Redressal Officer (GRO), who shall resolve the complaint within 14 days. If still dissatisfied, the claimant may approach the Insurance Ombudsman for adjudication. Non-compliance with the Ombudsman’s award attracts a penalty of ₹5,000 per day,” Chaudhary said.
He also informed that amendment in Insurance Law empowers IRDAI to issue directions to insurers and insurance intermediaries in the public interest, to protect policyholders, prevent mismanagement, and ensure proper governance, including ordering disgorgement of wrongful gains, and bringing insurance intermediaries under the ambit of this provision. Penalty limit has also been enhanced.
Published on March 30, 2026
