**Executive Summary**
This document is a response by the Finance Minister to a starred question in Lok Sabha regarding insurance claim settlements, specifically focusing on delays and grievances related to the IRDAI Master Circular on Health Insurance Business 2024. The response includes data on compliance with cashless settlement timelines, complaint resolution on the Bima Bharosa platform, complaints escalated to the Insurance Ombudsman, and Show Cause Notices issued for regulatory violations. The data covers periods from August 1, 2024, to September 30, 2025.
**Key Points / Main Content**
* **Cashless Settlement Timelines:**
* Insurers were required to implement systems adhering to cashless request timelines by July 31, 2024, with a one-hour limit for initial authorization and a three-hour limit for final discharge approval, effective August 1, 2024.
* The provided annexure details the number of cashless requests processed for pre-authorization and final authorization within specified timeframes from August 1, 2024, to May 31, 2025.
* **Bima Bharosa Platform and Complaint Resolution:**
* The Bima Bharosa platform is integrated with insurers' Complaint Management Systems (CMS).
* Insurers are required to resolve complaints within 14 days.
* For financial year 2024-25, 2,57,790 complaints were received, with 4,811 unresolved within the stipulated time (1.87% of total).
* For 2025-26 (up to Sept 30, 2025), 1,36,554 complaints were received, with 532 unresolved within the stipulated time (0.39% of total).
* **Insurance Ombudsman:**
* The Bima Bharosa system is not integrated with the Insurance Ombudsman system.
* Complainants unsatisfied with the insurer's resolution can file complaints with the Insurance Ombudsman in physical or electronic mode.
* 53,102 complaints were filed with Insurance Ombudsman offices in financial year 2024-25.
* **Show Cause Notices:**
* Eleven Show Cause Notices were issued during 2024-25 for violations of regulatory provisions relating to health and policyholders, including unnecessary claim deductions and improper claim rejections.
**Impact Analysis**
**Impact: Insurance Companies**
* **Impact**
* Insurance companies are impacted by the requirement to adhere to cashless settlement timelines and resolve complaints within specified periods. They also face potential regulatory action, such as Show Cause Notices, for non-compliance with regulatory provisions.
* **Action Required**
* Insurance companies must ensure their systems and procedures align with the IRDAI Master Circular, improve complaint resolution processes within the 14-day timeframe, and avoid unnecessary claim deductions and improper rejections to prevent further Show Cause Notices.
**Impact: Policyholders/Complainants**
* **Impact**
* Policyholders are directly impacted by the efficiency and timeliness of claim settlements and the resolution of their grievances. They have recourse to the Insurance Ombudsman if they are unsatisfied with the insurer's resolution.
* **Action Required**
* Policyholders should utilize the Bima Bharosa platform for lodging complaints and can escalate unresolved issues to the Insurance Ombudsman if necessary.
**Impact: IRDAI**
* **Impact**
* The Insurance Regulatory and Development Authority of India (IRDAI) is responsible for monitoring the compliance of insurance companies with the Master Circular and other regulatory provisions.
* **Action Required**
* IRDAI should continue to monitor insurance companies' compliance with the cashless settlement timelines and complaint resolution processes, issue Show Cause Notices for violations, and ensure effective grievance redressal mechanisms are available for policyholders.
Key Entities Referenced
Bima Bharosa: Online platform for registering insurance related grievances.
Insurance Ombudsman: An office that allows for complaints to be filed if an insurer provided an unsatisfactory resolution.
Insurance Regulatory and Development Authority of India (IRDAI): Regulatory body whose circulars and directives are central to the policy discussion on insurance claim settlements.
Insurance Regulatory and Development Authority of India (IRDAI) Master Circular on Health Insurance Business 2024: A key policy document setting the mandatory timelines for claim settlements.
GOVERNMENT OF INDIA
MINISTRY OF FINANCE
DEPARTMENT OF FINANCIAL SERVICES
LOK SABHA
STARRED QUESTION NO. *20
ANSWERED ON MONDAY, 01st DECEMBER, 2025/AGRAHAYANA 10, 1947 (SAKA)
Insurance Claim Settlement
*20. SHRI SRIBHARAT MATHUKUMILLI:
Will the Minister of FINANCE be pleased to state:
(a) the total number of instances of delayed cashless claim settlements, wherein the
mandatory timelines of one hour for initial authorisation and three hours for final discharge
approval were breached by Insurance companies since the implementation deadline of the
Insurance Regulatory and Development Authority of India (IRDAI) Master Circular on Health
Insurance Business 2024;
(b) the number of cases till date by which insurers failed to provide final resolution within the
mandated fifteen days from receipt of grievance;
(c) the number of grievances filed on the Bima Bharosa platform that were deemed
unsatisfactory by policyholders and subsequently escalated to the Insurance Ombudsman
for review; and
(d) the number of Show Cause Notices formally issued till date to Insurance companies for
contraventions relating to unnecessary claim deductions and improper claim rejections?
ANSWER
THE FINANCE MINISTER
(SMT. NIRMALA SITHARAMAN)
(a) to (d): A Statement is laid on the Table of the House.
*****STATEMENT AS REFERRED TO IN REPLY TO PART (A) TO (D) OF LOK SABHA
STARRED QUESTION NO. *20 FOR 01st, DECEMBER, 2025/ AGRAHAYANA 10, 1947
(SAKA) REGARDING ‘INSURANCE CLAIM SETTLEMENT’ RAISED BY SHRI
SRIBHARAT MATHUKUMILLI, HON’BLE MEMBER OF PARLIAMENT
(a): As per the provisions of Insurance Regulatory and Development Authority of India (IRDAI)
Master Circular on Health Insurance Business dated 29.05.2024, insurers were required to
put in place the necessary systems and procedures to adhere to the mandated timelines for
cashless requests by 31st July 2024. The one hour and three hour cashless authorisation
timelines were made effective from 1st August 2024. The data on compliance of cashless
settlement, as reported by IRDAI for 1st August 2024 to 31st May 2025 is as per Annexure-I.
(b) and (c): IRDAI has informed that Bima Bharosa platform is integrated with the Complaint
Management Systems (CMS) of the Insurers. Thus, the complaints filed in Bima Bharosa are
reflected in CMS of the insurers on real time basis and vice versa. A time period of 14 days
has been specified within which an insurer is required to resolve complaints.
• During the financial year 2024-25, total 2,57,790 complaints were received in Bima
Bharosa portal, out of which, for 4,811 complaints, the insurers have not provided the
resolution within the stipulated time, constituting 1.87 percent of the total complaints
received during the year.
• During the current year 2025-26 (up to 30th Sept, 2025), total 1,36,554 complaints
were received, out of which, for 532 complaints, the insurers have not provided the
resolution within the stipulated time, constituting 0.39 percent of the total complaints
received.
IRDAI has further informed that Bima Bharosa system is not integrated with Insurance
Ombudsman System and there is no provision in Bima Bharosa to escalate the complaints
automatically to Insurance Ombudsman. However, a complainant not satisfied with the
resolution provided by the insurers, has an option to file complaint with Insurance
Ombudsman having competent jurisdiction. Such complaint can be filed either in physical
mode or through electronic mode.
During financial year 2024-25, 53,102 complaints have been filed with Insurance
Ombudsman offices against the insurers seeking relief.
(d): Eleven Show Cause Notices were issued during 2024-25 on violations relating to Health
and Policyholders related regulatory provisions including unnecessary claim deductions and
improper claim rejections.
*****Annexure I referred to in reply to Lok Sabha Starred Question No. *20 for 01.12.2025
Data on Cashless pre-authorization
Number of Cashless Requests
Time % of Cases
processed for pre-authorisation
Within 1 hour 55,35,353 86.88%
>1 hours and <= 2 hours 5,40,941 8.49%
> 2 hours and <= 5 hours 1,98,367 3.11%
> 5 hours 96,959 1.52%
Total 63,71,620 100%
Data on final cashless authorization
Number of Cashless Requests % of
Time
processed for final authorisation Cases
Within 3 hours 54,92,758 96.69%
>3 hours and <= 4 hours 92,667 1.63%
> 4 hours and <= 8 hours 51,737 0.91%
> 8 hours 43,836 0.77%
Total 56,80,998 100%