IRDAI Takes Strict Stand on Health Insurance Claims Amid Rising Complaints

The insurance regulator IRDAI has adopted a firm stance following rising complaints about incomplete settlement of health insurance claims. More than half of all grievances under the Insurance Ombudsman system are related to health policies, with customers alleging that insurers are not paying the full claim amounts.

Regulator Demands Transparency and Speed
IRDAI has directed insurance companies to process claims with honesty, transparency, and promptness, warning that repeated deductions and delayed payments are eroding customer trust. The regulator is closely examining why full payments are not being made on health insurance claims, highlighting the seriousness of the issue.

On the occasion of Insurance Ombudsman Day, IRDAI Chairman Ajay Seth stated, “We have observed persistent shortcomings in health insurance. While the number of claims settled is substantial, the amounts paid are often below expectations. Insurers must ensure fairness and transparency in claim settlements.”

In the financial year 2024, of the 53,230 complaints received, 54% pertained to health insurance, underscoring the sector’s centrality in customer grievances.

Industry Challenges and Accountability
Insurance companies argue that claim reductions occur because healthcare providers often do not adhere to the pre-agreed rates with insurers. Conversely, hospitals accuse insurers of questioning legitimate medical procedures.

Chairman Seth emphasized, “Our expectation from insurance companies is clear—claims must be settled quickly, fairly, and transparently. Anything less undermines the trust on which the entire insurance industry relies.”