Settlement of cashless health insurance claims improves in 2025-26: FM Sitharaman
New Delhi, Dec 1
The number of complaints in which insurance companies have not resolved cashless health claim settlements within the stipulated time has come down to 0.39 per cent of the total complaints received in the first half (April-September) of 2025-26, Finance Minister Nirmala Sitharaman informed the Parliament on Monday.
In a written reply to a question in the Lok Sabha, the Finance Minister said during the financial year 2024-25, a total of 2,57,790 complaints were received in the Bima Bharosa portal, out of which, for 4,811 complaints, the insurers have not provided the resolution within the stipulated time, constituting 1.87 per cent of the total complaints received during the year.
During the current year 2025-26 up to September 30, a total of 1,36,554 complaints were received, out of which, for 532 complaints, the insurance companies have not provided the resolution within the stipulated time, constituting 0.39 per cent of the total complaints received.
As per the provisions of the Insurance Regulatory and Development Authority of India (IRDAI) Master Circular on Health Insurance Business, insurers were required to put in place the necessary systems and procedures to adhere to the mandated timelines for cashless requests by July 31, 2024.
The mandatory timelines have been fixed at one hour for initial authorisation and three hours for final discharge approval of cash health claim settlements.
The minister also said that the IRDAI has informed that the Bima Bharosa platform is integrated with the Complaint Management Systems (CMS) of the Insurers. Thus, the complaints filed in Bima Bharosa are reflected in the CMS of the insurers on a real-time basis and vice versa. A time period of 14 days has been specified within which an insurer is required to resolve complaints.
The IRDAI has further informed that the Bima Bharosa system is not integrated with the Insurance Ombudsman System, and there is no provision in Bima Bharosa to escalate the complaints automatically to the Insurance Ombudsman. However, a complainant not satisfied with the resolution provided by the insurers has an option to file a complaint with the Insurance Ombudsman having competent jurisdiction. Such complaints can be filed either in physical mode or through electronic mode.
During the financial year 2024-25, 53,102 complaints have been filed with Insurance Ombudsman offices against the insurers seeking relief.
The Finance Minister further stated that 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.
— IANS
Reader Comments
Good numbers on paper, but the ground reality can be different. The 1-hour/3-hour rule is great, but hospitals often delay submitting paperwork. The pressure is on them too. Also, 53,102 complaints to the Ombudsman last year is still a huge number. The system needs to be more proactive, not just reactive.
The integration with CMS is a smart tech move. Real-time tracking should theoretically reduce delays. But what about the quality of resolution? Just because a complaint is "resolved" in 14 days doesn't mean the policyholder is happy. Sometimes they just wear you down until you accept a lower settlement.
As an expat following Indian reforms, this is impressive. Mandating such short timelines for authorization is a bold step that many developed nations struggle with. The transparency in publishing these complaint figures is commendable. Hope the positive trend continues!
Only 11 show-cause notices for violations? That seems very low given the scale of the industry. The real deterrent is strong penalties and making examples of companies that unnecessarily deny claims. The fear of regulator action will clean up practices faster than any portal.
This is a relief for common families. Medical emergencies are stressful enough without fighting for cashless approval. The 3-hour discharge rule is a blessing. Earlier, we had to wait half a day just for paperwork. Small steps, but they make a big difference in people's lives. ðŸ™
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