Health Insurance Complaints in India Are Surging: What Policyholders Need to Know (And How to Protect Yourself)

Health insurance is meant to offer peace of mind. Yet, for thousands of Indians, the experience is unexpectedly stressful — marked by delayed claim approvals, unfair deductions, opaque explanations, and a lack of information at the time of purchase.

Recent data from the Mumbai Insurance Ombudsman highlights how serious the problem has become. Health insurance complaints have doubled in six years, and now account for 75–80% of all grievances filed. In 2023-24 alone, Mumbai recorded 7,789 health insurance complaints, one of the highest volumes seen in the country.

This surge is not just an administrative statistic — it reflects the growing frustration of policyholders who are left financially and emotionally overwhelmed during medical emergencies.

There are several recurring themes behind rising grievances:

1. Partial or reduced claim payments
   Insurers deduct amounts without clear justification — citing sub-limits, non-payable items, or lower admissible rates.
   
2. Complete claim repudiation
   Often due to alleged non-disclosure of pre-existing illness, lack of active line of treatment, or “hospitalisation not required”.
   
3. Confusing policy terms
   Policies are filled with technical jargon. Most customers are never explained the exclusions, waiting periods, or sub-limits.
   
4. Hospital overcharging
   Hospitals may bill aggressively, leaving patients vulnerable when insurers restrict pay-outs.
   
5. Post-Covid awareness and higher usage
   More people are using health insurance today — leading to more disputes when expectations and payouts don’t match.

Even when policyholders escalate disputes, the redressal journey is challenging.

In many ombudsman centers, hearings take 6 months or more, despite a mandatory 3-month deadline. Moreover:

1. There is no unified digital portal for tracking case status.
   
2. Policyholders are often asked to re-submit documents multiple times, even after uploading them online.
   
3. Cases are sometimes closed without adequate explanation, shocking families who were counting on the outcome.

For families already struggling with medical costs, these delays can be devastating.

Most grievances are not caused by fraud or misconduct — but by lack of clarity at the time of purchase.

Customers depend entirely on agents, and rarely read 20–30 page policy wordings. Terms such as:

1. Waiting period
   
2. Co-pay
   
3. Sub-limits
   
4. Daycare vs. OPD
   
5. Modern treatment clauses

are poorly understood.

This knowledge gap often leads to surprises during claims, forcing customers into disputes they are unprepared for.

To reduce future risk:

1. Understand your policy wording before buying
   
2. Check limits: room rent, modern treatments, organ donor, robotic surgery
   
3. Prefer policies with no or low co-pay
   
4. Keep medical history disclosed and documented
   
5. Ask for a cashless claim process whenever possible
   
6. Maintain a claim file with bills, prescriptions, reports, and admission notes

If your claim is delayed or rejected, don’t settle silently. There are mechanisms to fight back.

If you experience:

1. Unreasonable deductions
   
2. Claim rejection
   
3. Delay beyond TAT
   
4. Policy mis-selling
   
5. Lack of response from insurer

Professional mediation can help secure settlements and clarity.

Organisations like Insurance Samadhan assist policyholders in navigating disputes, collecting evidence, drafting representations, and escalating cases — improving chances of resolution.

Health insurance can be empowering — but only if policyholders understand their rights and insurers communicate transparently.

If your claim has been rejected, delayed, or unfairly reduced, you don’t need to fight alone.

Click here to register your complaint with Insurance Samadhan

Visit our website: insurancesamadhan.com

Mail us at corporate@insurancesamadhan.com