Parliament Question: Rejecting of Claims by Private Health Insurance Companies

GOVERNMENTOFINDIA MINISTRYOFHEALTH AND FAMILYWELFARE DEPARTMENTOFHEALTH ANDFAMILYWELFARE LOK SABHA UNSTARREDQUESTION NO. 1146 TOBE ANSWERED ON24TH JULY,2026 REJECTING OFCLAIMS BYPRIVATEHEALTH INSURANCE COMPANIES †1146. SHRIDEVESH SHAKYA: Will the Minister of HEALTHAND FAMILYWELFAREbe pleased tostate: (a) whether the Government is aware that private health insurance companies are rejecting claims for hospital admissions advised by specialist doctors, citing grounds such as 'non- medicalnecessity'or'exclusion'therebyadversely affectingthetreatmentofpatientsandif so, the detailsthereof; (b) whether any national standard guidelines or a medical audit system are proposed to prevent insurance companies from interfering with clinical/medical discretion, if so, the detailsthereof; (c) whether the Government in coordination with the Insurance Regulatory and Development Authority of India (IRDAI) and health sector regulators is considering a mandatory policy to give overriding priority to the clinical judgment of the attending doctor to their, if so, the detailsthereof; and (d) the details of the medical claim applications received and claims rejected on the grounds of the said 'non-medicalnecessity' or 'exclusion' during the last three years, company-wise? ANSWER THE MINISTER OFSTATEIN THE MINISTRYOFHEALTHAND FAMILYWELFARE (SHRIPRATAPRAOJADHAV) (a) to (d): Insurance Regulatory and Development Authority of India (IRDAI) has informed that the insurers assess claims on the basis of policy conditions and merits of each individual case, taking into consideration the clinical records, the treating medical practitioner's assessment, applicable medical standards, Standard Treatment Protocols, wherever available, and the terms and conditions of the policy, for determining their contractual liability under the health insurance policy. Further, no proposal is underconsideration with IRDAI toaccord overriding precedence to the clinical opinion of the treating doctor for determining insurance claimliability. IRDAI captures data relatingto the overall repudiation of health insurance claims of insurers, and at present does not capture claim repudiation data segregatedon specific grounds such as "non-medical necessity", or "exclusion". Accordingly, insurer-wise data on repudiations attributabletothese specific reasons isnot available. *****