Is your medical claim stuck? Find out why you face problems in health insurance claim settlement and how to avoid them
After five months of providing what was asked of him, he was told that his claim had been rejected on the grounds of ‘serious discrepancies in the event of hospitalisation’. This, after Pal offered counter-proof for the lapses mentioned by the insurer. “I did not have the strength to pursue the case after five months of back and forth with the insurer,” says the 36-year-old. His claim amount was Rs.1.14 lakh.
Pal isn’t the only one nursing a grudge against health insurance companies over claim settlements. As per the Council for Insurance Ombudsmen’s annual report 2022-23, of the 51,103 insurance complaints received by it between 1 April 2022 and 31 March 2023, nearly 50.6% or 25,873 complaints were related to health insurance. As high as 93.14% of the total entertainable complaints disposed of were about ‘partial and total repudiation of claims by insurer’.
According to a dipstick online survey by ET Wealth, nearly 88% of policyholders have faced a problem in claim settlement, with 59% citing issues with claim rejection and partial payments. As many as 69% claimed their grievances were not suitably resolved by the insurer. “Dealing with health claim rejections can be especially tough when you’re already grappling with a medical issue, but the insurance industry pays more than 90-95% claims, as the data available in the public domain shows. Some claims are rejected on the basis of just a few parameters,” counters Bhaskar Nerurkar, Head, Health Administration Team, Bajaj Allianz General Insurance.
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