Health insurance claim hustle:
Nearly 40% of patients encountered obstacles in securing their health insurance claims. A survey revealed that 43% of health insurance policyholders, who filed claims within the past three years, faced difficulties obtaining reimbursement or settling payments at hospitals post-treatment.
The survey conducted by LocalCircles highlighted that general insurance policyholders faced the greatest challenges in processing health insurance claims compared to other types of insurance, such as motor insurance. Policyholders cited issues like claim rejections, partial approvals, and prolonged settlement times for hospital bills as common hurdles.
Six major issues were identified by the survey respondents, including insufficient disclosure regarding claim exclusions and eligibility criteria, contract ambiguity due to complex terminology, claim rejections based on pre-existing conditions, eligibility criteria beyond pre-existing conditions, and complexities tied to crop insurance regulations.
Among the recurring concerns reported by consumers, the rejection of health insurance claims, including policy cancellations by insurance companies, stood out. Policyholders described instances where claims were denied by categorizing a health condition as pre-existing or only partially approving claims. They emphasized the time-consuming nature of the claims process, often requiring extensive efforts by policyholders and their families, sometimes even delaying discharge from hospitals.
In some cases, patients experienced delays of up to 10-12 hours post-discharge while awaiting claim processing, forcing them to bear additional costs for extended hospital stays. To address these issues, 93% of insurance holders expressed support for IRDAI mandating insurance companies to publish monthly data on received claims, rejections, policy approvals, and cancellations on their websites. Additionally, they urged collaboration between IRDAI, the Health Ministry, and the Consumer Affairs Ministry to ensure fair and expedited processing of health insurance claims without causing harassment to policyholders.
Earlier this year, the Department of Consumer Affairs recommended changes to insurance regulations to combat mis-selling, proposing that insurance agents maintain audio-visual records of their sales pitches to ensure prospective buyers are fully informed about policy features. IRDAI was reportedly discussing measures to enhance accountability across all stakeholders, including the implementation of frameworks for audits of solicitation processes, customer outcomes, and grievance redressal mechanisms.
