43% of health insurance policyholders face hurdles in processing claims: Survey- Republic World

Challenges in Health Insurance Claims | Image: Pixabay

Challenges with health insurance claims: As many as 43 percent of health insurers experienced problems processing their claims after treatment, according to a recent survey by LocalCircles. The study found that those with general insurance experienced the most problems compared to those with auto or other insurance.

Among respondents who had made a claim in the past three years, almost four in ten patients had difficulty receiving their entitlements or paying outstanding payments in hospitals after treatment.

Policyholder issues identified

The study sheds light on six key issues faced by policyholders, including inadequate disclosure regarding claim exclusion and eligibility criteria, contractual ambiguity due to complex terminology, claim denials based on pre-existing conditions, criteria eligibility beyond pre-existing diseases, and complications arising from crop insurance regulations.

Additionally, policyholders expressed frustration over frequent claim denials and policy cancellations by insurance companies. They recounted cases in which insurers denied claims by categorizing certain health conditions as pre-existing, or offering only partial refunds.

When describing the cumbersome process of claiming health insurance, many policyholders said they spent a lot of time and effort, often until the last day of hospital admission, to facilitate their claims. In some cases, patients experienced delays of up to 10-12 hours after discharge due to ongoing claims processing, leading to additional financial burdens if they chose to extend their hospital stay.

Transparency of policyholders is advocated

Suggesting solutions, 93 percent of respondents called for greater transparency from insurance companies, urging regulators such as the Insurance Regulatory and Development Authority of India (IRDAI), the Ministry of Health and the Ministry of Consumer Affairs to work together work in ensuring fair and honest insurance. efficient processing of health insurance claims, without subjecting policyholders to unnecessary harassment.

In response to increasing complaints about mis-selling of insurance policies, the Ministry of Consumer Affairs has proposed regulatory revisions, including mandatory audiovisual recordings of sales pitches by insurance agents. This measure is intended to ensure that potential buyers are fully aware of the policy features, rather than focusing solely on the positive aspects.

Notably, IRDAI is considering enhanced accountability measures for all stakeholders, including frameworks for auditing application processes, assessing customer outcomes and strengthening redress mechanisms.