At Centrico Insurance Repository Limited (CIRL) we are of the opinion that health insurance should be a matter of financial securityand certainty not confusion and worry. But the number of health insurance-related complaints in India has been increasing exponentially and too many families find problems at absolutely the wrong time: during an illness or hospital stay. This article describes the causes behind it, their real-world effect on policyholders, and what actions you can take today to minimize risk and protect your rights.

What’s behind the increase in complaints?

A handful of repeatable habits account for the rise in grievances:

• Complex policy design and opaque language: The clauses of modern health policies are too detailed — waiting periods, sub-limits, exclusions for some procedures or device types and not everybody necessarily understands them. The consequence is surprise deductions and disputes at claim time.
• Higher utilization post-pandemic: More people are using health care services and claiming, so more gaps between expectation and cover are being revealed.
• Price pressure on the provider network: Hospitals and clinics submit more bills for advanced procedures and devices; insurers counter by adopting tighter admissibility checks and reductions, sparking disputes.
• Operational friction: Particularly insurer processes (document handling TATs and communication) are often mentioned as items to cause dissatisfaction and escalation.

The Net Result: partial payments and raw health insurance claim denials – which fuel formal complaints and consumer anguish.

The road to redress is often longer and more tortuous than it need be.

But filing a complaint is just the beginning. Many policyholders encounter further obstacles:

• Case timelines exceed expected service-levels.
• The supporting documents needed are ask again and again, or the uploaded docs are not complete.
• Decisions (including being closed) are made without sufficient explanation or calculation shown.
• There is not great transparency on where the case stands and next steps in escalation through regulator channels like IRDAI health insurance grievance procedure.

The result is that families confronting medical expense shortfalls are expected to navigate both health recovery and beleaguered bureaucracy – a situation that wears on finances and well-being.

What policyholders commonly miss

Most disagreements are not malicious but stem from miscommunication at the time of purchase. Commonly overlooked terms include:

• Wait times and coverage for pre-existing conditions.
• Co-payment and Sub-limit rules for parts like ICUs, room rent, implants, prosthetics.
• Differences in daycare protocols, OPD and inpatient care.
• Chain-of-title provisions and caps on new therapies.

Here at CIRL, we advocate Know Your Insurance Policy as the bedrock of prevention: knowing what is covered – not covered; where caps apply allows you to plan and avoid unpleasant surprises during a claim.

Practical measures to protect yourself (checklist)

Following are three steps to decrease the probability and magnitude of an argument:

• Read and verify the policy language before buying. Point to areas of waiting period, co-pay, sub-limits and exclusions. Should an agent or broker offer oral assurances, request them in writing. This is part of Know Your Insurance Policy philosophy.
• Keep medical history documented. State previous conditions in application clearly from the outset and keep receipt or consultation notes. Failure to disclose information is one of the top reasons why health insurance claims get denied.
• Opt for policies with clear-cut benefits and a smaller number of sub-limits. Opt for plans with a low or no co-pay and predictable room-rent clause, as much as possible.
• Where available and appropriate, make use of cashless pre-authorization facilities. For elective operations, ask for approval and save the letter of authorization.
• Keep a claims file: hospital bills, prescriptions, discharge summary, investigation reports and itemised bill.
• Make payments on time and save receipts. In delaying the payment of a health insurance premium, you run the risk that there will be a time gap; proof of payment, and renewals information can be useful in case there’s any dispute about retroactive coverage.
• e-insurance account and policy documents delivery preference for digital form. It is easier for the customer to get access to service his documents with e-insurance account and strong online policy management, while minimizing errors in submission and creating an auditable trail of contact.
• Save copies of all correspondence with the insurer emails, chat transcripts and confirmation numbers. This will be useful when you escalate or go to a regulator.

When a claim is delayed, reduced or denied

If you get an unfavourable result:

1. Ask for an itemized, written explanation of the carrier’s decision results detailing out the policy clause cited and admissible versus billed figures.
2. File an internal complaint with the grievance redressal cell of the insurance company; keep a record of the reference number and expected TAT.
3. If you don’t receive a satisfactory response from the insurer, take it up with the insurer’s senior grievance officer. Document every escalation step.
4. If escalation within also does not work, you can lodge an IRDAI health insurance complaint or go to the Insurance Ombudsman. CIRL can help to identify the right escalation pathway and provide the documentation mandated by the regulator.

When to go for professional help and how CIRL can help

Specialist help is useful for intricate cases and to the large disputes. CIRL provides:

• Interpretation/Clearing Policy for instruction on how a claim is to be interpreted and its strength.
• Help to put medical records and billing into a connected submission.
• Assistance in drafting representations to insurers and, as the case may be, escalation to IRDAI health insurance grievance or the Ombudsman.
• Assistance in the management of policy online and creation of an e insurance account for greater transparency and to simplify interactions from here on.

It is advisable to engage the expert support if the deductions are substantial, claim is denied on unclear grounds and TATs are repeatedly not met.

Conclusion

The increasing number of health insurance complaints in India is a signpost for a healthcare-financial ecosystem that we have not been able to decode. “The greatest defence to policyholders is being clear: document disclosures, read your contract, keep good records, manage renewals and payments and use digital tools for transparency. When there are disputes, escalate systematically and utilize regulatory pathways that already exists.

Our mission at CIRL is to diminish friction in the customer/insurer ecosystem by delivering better access, easier online management of insurance policies and instilling confidence for families when advocating for their health insurance consumer rights. If you follow the checklist of considerations above and avail yourself of digital tools like an e insurance account, you should drastically reduce the chances of surprise deductions or claim disputes — as well as be much more equipped to navigate them if they do occur.

FAQ (brief)

Q: What happens if I’m denied for non-disclosure?

A: Go over the application and medical records right away. If you have informed them, collate evidence (consultation records, prescriptions) and take your claim higher up the insurer. If not resolved, lodge an IRDAI health insurance complaint or ombudsman complaint.

Q: Will late premium payment result in rejection?

A: It could go to both continuity and admissibility.” Retain confirmation of payment and apply for backdate loading according to the terms of your policy only.

Q: What is the benefit of having an e-insurance account?

A: An e insurance account consolidates your policies across insurers, you can manage your policy online and it is maintained as a valid record – helping prevent delays in claims process due to lack of documents.

CIRL’s advisory teams can help you with policy interpretation, e-insurance account set-up and dispute support to ensure that you are protecting your health and your finances.