Public sentiment is characterized by frustration and distrust towards health insurance companies in India, driven by a surge of complaints regarding claim rejections, poor customer service, and perceived exploitative practices. Many individuals voice personal grievances, describing healthcare insurance as a scam exacerbated by greed and a lack of accountability. There is a strong desire for government intervention and systemic reforms to protect consumers.

Healthcare Insurance Companies

Government of India

Policyholders

I want to know how many private insurers are refusing claims and how many govt insurers are refusing claims and what is the total amount of the refused claims..

DwaiG91

Hdfc ergo prolly has best stats as of now? Just confirming with gurus here.

Reader_Cat1994

Is it really only celebrities and powerful figures who can access cashless claims? This entire industry desperately needs a complete overhaul. Pathetic man !

AdExtension6369

That’s a huge percentage right? How come every company out their claim 93-99 pc claim settlement then?

TheGalaxial

In India health insurance is like paying premium and then keeping your fingers crossed. 

I had claimed for hydrocele for my son which was rejected by Care saying birth defect. However, doctor had mentioned in writing that it was not a birth defect. Also, this incident happened when he was 5 years old and we had a sonography when he was 1 year old which didn’t had any mention of hydrocele. 
As per them, thing which was not there when he was 1 year and had occurred when he was 5 years is a birth defect. 

Eventually, the claim was settled by corporate policy.

NagarMayank

Just saw niva bupa reply on one of the posts on Instagram regarding this case.

Baller_Brute

basically we need Insurance claimers support group at grassroot levels to help each other incase someone is going through such atrocities, need people to make posts on Linkedin, Twitter, Insta, start the proceedings with complaints to the insurer and then RBI if no resolution. 

because its totally clear that these companies won't do jacksh!t if your case is not there on social media getting views and likes. or you have RBI backing you after months of delay. 

we need social movement and awareness

Long-Possibility-951

I have National Insurance mediclaim, my in-laws also have the same. It is a govt insurer. Till date, they have not rejected our claims.. We have opted for cashless sometimes and most of the times, for reimbursement.

Cleaned up link:

https://www.financialexpress.com/trending/biggest-scam-in-india-angel-investor-rips-into-insurance-companies-after-niva-bupa-denies-rs-61-lakh-claim-to-a-family/3962188/

senpahII

Do you knowaverage amount claim paid is just about Rs 32000 only. Put RTI and you will get data or download annual reports of IRDA and insurance companies. Government insurance claims are almost settled fully. Then large private companies and last is individual insurance claims. 

If you claim 10 lakhs and then approve say 4 lakhs it would still count in claims approved.

saransh000

Health insurance is a lottery ticket. Treat it like that. 

Plan a substantial emergency fund, good savings, and good investments. 

Never rely on health insurance any more than you'd rely on winning a lottery ticket. If your luck is good and it works, great. But never _rely_ on it. Luck is not a plan.

tech-writer

Question here: let's say I claimed for 5 lakh and insurer approved 1 lakh, what is my settlement ratio ? Is it still 100 percent ??

vjstylo

Unfortunately, in India, almost everything feels like a sophisticated scam. Insurance policies are aggressively sold to the middle and upper-middle class by creating FOMO and spreading fear. Yet, when it comes to actual hospitalization, getting these companies to pay is a herculean task. Even if one fulfills every requirement listed in the policy, it is highly likely that the company will harass the claimant at the time of need.

Legal proceedings in India drag on for an eternity, and every company takes advantage of this fact. It is often wiser to focus on maintaining good health and building your own emergency fund that compounds at a decent annual rate. That way, you avoid paying exorbitant premiums to these companies only to face harassment later. To say the least, this country can be a depressing place to live in.

RecluseWithSelfDoubt

it is wild to see the young generation fall for the obsession of health insurances at a massive scale. they should understand that in health insurances, only a tiny insignificant participants are expected winners. 

even the more discussed mlm techniques are better than health insurances in the sense that all participants are more or less uniformly winners.

effectively, if a scam happens in the health insurances like rejections even at large-scale, the overall fightback impact will still be very insignificant due to already insignificant expected number of winners. so, it seldom impacts the mainstream news.

CandidFalcon

Well, this is concerning. I was planning to buy personal health insurance by the end of this year, this makes me go more into action paralysis.

Lucky_Editor446

Official response from Niva Bupa is here. I can understand where they are coming from. Hospitals can ask willy nilly any random amount towards cashless. That doesn't mean that it will be honoured. But as days progress, the incremental cashless gets honoured.

https://preview.redd.it/4gzkxszfrumf1.jpeg?width=891&amp;format=pjpg&amp;auto=webp&amp;s=e63df473d9021937f6541aacdc9dd3e73fce6d06

Banyan-FA

So which has the best track record? I was considering niva bupa

QuiteSchrute

Yesterday my claim for niva was rejected for cashless. I was trying to discharge my wife. A lot to be seen how they will go ahead with my insurance claim but I am skeptical with niva for now.

Unfair_Roof2011

Count me in too!

My cashless claim was rejected for my parent for a crucial surgery, and I'm exploring options on how to escalate this further.

bornhippie2411

I know it's unrelated but help me to underwstand. I have an uncle (70) and an aunt (65). They have a child who is nearly 40 years old and has severe mental health issues. Since both of them have a pension as a source of income, I wanted to ask: is it advisable for them to get **term insurance** at their age? Are they even eligible for it, or is term insurance only meant for people who are currently employed? Would be a huge help if you could answer it.

Aggravating_Tank9397

Broad-Research5220

My brother was treated for depression in AIIMS Delhi. Depression is common but not for insurers. I contacted many insurance companies they rejected his insurance all together. I was ok with putting conditions and riders for future liability due to his depression or related issues. But they refused. 

So income is not the issue but their perception of risk and liability. In your case, the parents age is a big risk which not many insurers will agree to.

Kindly Check CSR and ASR before buying any insurance

missingchai

Claim settlement ratio is golden

Care, Njva Bupa are shit as their CSR sucks, for health insurance better stick with Public sector Insurers or at best Tata AIG

Greedy_Rise_6567

The health insurance in India is just a scam, unless you are a celebrity or an influential person. You can read big benefits and big claims on advertisements and keep on paying heavy premiums every year till you don't get a need to get insurance benefits. 

I have paid INR 1.64 lakh as an annual premium for my mother's health insurance policy, with reduction in Waiting period for PED. Trusting the brand reputation and appealing advertisements, made me go for ICICI LOMBARD Elevate health insurance policy for my mother (72 years when policy bought). I honestly declared all the known health conditions when purchasing the policy.  I got the policy issued but as the waiting period for PED was getting over, during renewal, they conducted a so-called re-assessment of health condition, and issued a counter offer with a permanent exclusion for Spine and related diseases. Spine, that almost covers your entire body and nervous system! This is not even among the list of 16 diseases allowed by IRDAI for consideration of permanent exclusion. 
Excluding the complete body part as a blanket exclusion, they increased the premium to ₹1,77,000/- for remaining coverage. And this is done when there is no gap in the policy continuity. Any diseases diagnosed during policy continuity but not known at the time of inception of policy should not be counted as PED. But wait ! The insurance company support team told me as the age is above 60 years, they reconduct the assessment every renewal year and can approve, reject or add add permanent exclusions depending upon risk factors!

Come on ! What is the insurance meant for? Risk free coverage?  As you grow older, you are supposed to be disease free. Even if you sneeze, they may exclude breathing and related issues as permanent exclusion!  They have full authority to decide their own rules, add or deny claims at their will, but you must pay in time every time. And as you cross 50, they will start adding co-pay, start adding exclusions or add various ways to minimize their scope of risk  coverage and one day, they will consider you risky enough to exclude all your body parts but bill you for every ounce of blood in your body. If there wasn't a risk, why would you charge a hefty premium of ₹1,64,470/- for one year? 

And God forbid, if you happen to be in a situation of emergency when you need the insurance coverage the most, your approvals will turn into rejections unless you are a top notch celebrity, politician or an influential person. They can declare anything as "not disclosed" or hidden by customer. You keep appealing from IRDAI to Ombudsman or from Finance Ministry to anyone else, no one pays any attention. You file a case in court of law, they will file an appeal in higher court against the judgement of it was in your favour! Unless you are an attorney and have enough time and money to spend in court cases, there's no hope! They have a legal team for this purpose.

I personally have now decided, to invest that money in some good instruments like MF or crypto etc instead of wasting on premiums where there is no guarantee that you will benefit from it when you need it the most.

Insurance in India is a big Scam. Risk is there in either option! But there are better chances that your investment yields cash that can still save your life but can't trust these scammers! With a mixed bag of assets in MFs or crypto, you can expect an average return in the worst conditions to be in the 12-22% range. Which could be Even better in some special cases. Instead of wasting money on unreliable cases, put it to work as a medical or health care fund in appropriate investment instruments. Over a period of time, this huge corpus will be a saviour for you and all your family's medical and health coverage needs, be it OPD or IPD or advance treatment in a foreign country.

And, I am not here trying to change anyone's opinion or mind. I am not the only one who has faced challenges from these health insurance scammers!  Everyday there is one new article on Google news. The Internet is full of such stories where people felt helpless even after being a loyal customer for 35 years of continued premium payment.

yogs4rd

What If you get to know about your bp or diabetes after taking the insurance… what should be done in that case ?

Intelligent_Wish_740

for 1., wouldn’t diabetes emerge during the mandatory health checkup during onboarding for the insurance?

zyrkor90

Every system in india is outdated.. Everything needs an update

Quiet_Badger3509

[deleted]

Save money do not eat oily and momos go for a walk. Do yoga.
And show middle finger to insurance companies

UpDown_Crypto

ImprefectKnight

Isn't it beneficial to ask for medical tests by the insurance company itself and taking it in writing so, that they can't reject our claims if new complications arises or they change their wordings?

yoboja

Why don’t insurance company asks for full body checkup when buying the insurance? Can’t we do a full body check and attach the reports? How does insurance company confirm that particular medical issue was pre-existing?

SlytherinSymbiosis

I purchased policy on 30th April 2025 and had a heart attack on 19th May 2025 and was admitted in hospital for 6 days.

I got treated with medicines only without any surgery and my thrombus got dissolved on its own, I have disclosed my condition to Niva Bupa online portal on 27th May 2025. 

Do I need to do something else?

Wikileaks_2412

If I have a policy with the same insurer for 4 years then all pre-existing conditions are allowed whether disclosed or not . Is my understanding correct ??

bish888

How many years is this pre-existing disease clause active? Do we have to re-declare every year on renewal? Also would it be better to just undergo a medical test and submit the results on renewal?

nishbipbop

First off, Kudos... these are kind of stories we need, common man (or woman) winning a battle of 'David vs Goliaths' (them insurance companies). Excellent detailing, but commendable perseverance.

Just wondering, what exactly was the mistake in Discharge Summary (not sure if I caught the mistake) ? What is the nature of checking you performed ? What kind of mistakes were you watching out for ?   
  
And didn't your insurance offer cashless facility or you went out of network ?

Professional_Row_967

National-Concern-273

Similar thing happened to me. Star health rejected my claim without giving any reason. No help from them or agent. Several emails, calls, going in person, no help or atleast reason for rejection.

 I filed a case with ombudsman. Had to send all original docs by courier. Within few months, they contacted Star for explanation. Star health agreed to settle claim. No court hearing, no mediation. Straight up agreed to pay. They even reimbursed bills that were not related treatment.

Lesson : Insurance companies reject for no reason. They can get away with it. But always file case with ombudsman. It is easy. How much ever late it is, file case. I don't think there's a time cut off. Most hospitalised people would be tired to go after insurance, and that's what they rely on.

rajeevriitm

If someone is diagnosed with a major illness like cancer or heart disease, it's almost impossible to get an insurance. So take it while you're in good health

My friend had a heart surgery some years back for a by birth issue which he got to know by then only. Some insurers do have the heart plan where they cover cases like him but after some waiting period. But don't know whether they will actually honor the claims, if any, in the future or not. What do you suggest?

falcontitan

Consistent_Recipe_41

Do get a fresh new insurance policy from other provider, also if possible let the current insurance continue (if you can afford it) for 2 years until new one's waiting period is over.

The main reason to close the current policy is because it has the disputed claim timeline with it, which will always be seen by future underwriters and increase your premium &amp; claim settlement process for stupid reasons. They are always keen on sucking up money one way or another.

roxor_17

I can relate to this post. We even had a similar experience with Star health and I used chatgpt to write long emails to them threatening them and ultimately took them to the ombudsman where we won. This was the first instance as this happened because they denied major portion of my mom's knee replacement surgery cost.

Then again  star health refused to renew my parents's policy and then we again filed a complaint with the Bima Bharosa portal.

O-Astronomer

Insurance advisor here. 

Excellent job. Unfortunate your agent didn't help when needed.

insurancepal

amolnchavhan

Objective_Novel_7250

Congratulations and thanks for sharing. Good to know the redressal mechanism works. Please share the name of the insurance company

Original-Bottle-1946

smartfit30

Great!! Which insurance company?
And can you tell me what's ombudsman?

Spiritwarrior1124

True warrior amongst us! Kudos my friend.

whackybrain

Hi OP, how much old is your insurance? You stated that your policy was rejected for non-disclosure. So just wanted to know if your policy is more than 3 years old.

AdonisGhoul

Your example will be an inspiration for the coming times when there are more such scenarios.

D0b0d0pX9

This is really an amazing post, from an amazing person. Not just your persistence, but your careful and thorough follow up, and persistence, and your detailed notes. Really amazing. Kudos to you, OP and thanks for sharing.

Awkward-Chair2047

Can you tell me what was the problem in discharge summary that triggered the problem? Was it wrong diagnosis or incorrect details like name, age etc?

Substantial_Point700

What was the problem with the discharge summary?

dc1222

Can anyone tell :  IRDAI and Insurance Ombudsman are same or different ? How are they connected ?

anacondaonline

tatasuv

The health insurance in India is just a scam, unless you are a celebrity or an influential person. You can read big benefits and big claims on advertisements and keep on paying heavy premiums every year till you don't get a need to get insurance benefits. 

I have paid INR 1.64 lakh as an annual premium for my mother's health insurance policy, with reduction in Waiting period for PED. Trusting the brand reputation and appealing advertisements, made me go for ICICI LOMBARD Elevate health insurance policy for my mother (72 years when policy bought). I honestly declared all the known health conditions when purchasing the policy.  I got the policy issued but as the waiting period for PED was getting over, during renewal, they conducted a so-called re-assessment of health condition, and issued a counter offer with a permanent exclusion for Spine and related diseases. Spine, that almost covers your entire body and nervous system! This is not even among the list of 16 diseases allowed by IRDAI for consideration of permanent exclusion. 
Excluding the complete body part as a blanket exclusion, they increased the premium to ₹1,77,000/- for remaining coverage. And this is done when there is no gap in the policy continuity. Any diseases diagnosed during policy continuity but not known at the time of inception of policy should not be counted as PED. But wait ! The insurance company support team told me as the age is above 60 years, they reconduct the assessment every renewal year and can approve, reject or add add permanent exclusions depending upon risk factors!

Come on ! What is the insurance meant for? Risk free coverage?  As you grow older, you are supposed to be disease free. Even if you sneeze, they may exclude breathing and related issues as permanent exclusion!  They have full authority to decide their own rules, add or deny claims at their will, but you must pay in time every time. And as you cross 50, they will start adding co-pay, start adding exclusions or add various ways to minimize their scope of risk  coverage and one day, they will consider you risky enough to exclude all your body parts but bill you for every ounce of blood in your body. If there wasn't a risk, why would you charge a hefty premium of ₹1,64,470/- for one year? 

And God forbid, if you happen to be in a situation of emergency when you need the insurance coverage the most, your approvals will turn into rejections unless you are a top notch celebrity, politician or an influential person. They can declare anything as "not disclosed" or hidden by customer. You keep appealing from IRDAI to Ombudsman or from Finance Ministry to anyone else, no one pays any attention. You file a case in court of law, they will file an appeal in higher court against the judgement of it was in your favour! Unless you are an attorney and have enough time and money to spend in court cases, there's no hope! They have a legal team for this purpose.

I personally have now decided, to invest that money in some good instruments like MF or crypto etc instead of wasting on premiums where there is no guarantee that you will benefit from it when you need it the most.

Insurance in India is a big Scam. Risk is there in either option! But there are better chances that your investment yields cash that can still save your life but can't trust these scammers! With a mixed bag of assets in MFs or crypto, you can expect an average return in the worst conditions to be in the 12-22% range. Which could be Even better in some special cases. Instead of wasting money on unreliable cases, put it to work as a medical or health care fund in appropriate investment instruments. Over a period of time, this huge corpus will be a saviour for you and all your family's medical and health coverage needs, be it OPD or IPD or advance treatment in a foreign country.

And, I am not here trying to change anyone's opinion or mind. I am not the only one who has faced challenges from these health insurance scammers!  Everyday there is one new article on Google news. The Internet is full of such stories where people felt helpless even after being a loyal customer for 35 years of continued premium payment.


Do not fall for their promises, figures and big claims shown on their advertisements or news articles. Always trust yourself and your intuition better than you trust these business hoaxes and any government! Do not trust anyone, including their own employees who 'talk on the recorded line' to bring you into the trust zone! Always read the fine prints carefully before making a payment and do extensive research on claims history from the IRDAI site. When big names like Niva Bupa etc get excluded by the likes of Max Hospital, you can't take a chance on less reputable names at all. And insist on official written statements or communication for whatever anyone claims as a benefit and coverage.

Jai Ganesh Jai Ganesh deva 

https://youtu.be/Bm3LNWYbfW8?feature=shared

FishNervous7722

Hi. Lawyer here. Yes, you seem to have a strong case since there appears to be a procedural lapse on their part. What the MRI showed was age-related changes and not a diagnosis. Plus, since you had an active HDFC Ergo policy before the MRI, there was no intention to hide anything. Their denial seems unfair and can be challenged before the insurance ombudsman or consumer court. You can also send them a legal notice calling upon them to reconsider and approve your claim, in addition to providing other reliefs.

Ritika2485

You have a valid case to challenge the claim denial. Since the insurer never shared the proposal form with you for verification, they cannot hold you liable for non-disclosure. The MRI finding cited is age-related and not a material condition requiring disclosure, especially since you relied on your doctors' opinion.

You may first file a written complaint with Care Health. If not resolved within 30 days, approach the Insurance Ombudsman with proof.

It is also advisable to send a legal notice through a lawyer demanding claim settlement, failing which further legal action may be taken under the Consumer Protection Act.

Let me know if you need assistance.

- Adv Ahammed Sha

adv_ahammedsha

If they have already repudiated your claim, file a consumer complaint.

puzzledlawyer-

How did they get to know if the mri done?

Own-Software8385

Get a letter from Dr stating it is age related. And submit that as well.

intvijay

nvmnit

Long time customer of New India Assurance, I recommend them to everyone. They might look technologically backward (website, branding, communications) but they in my many, many claims, they have never once given me the run about like the companies I got through my corporate claims. One occasion they have paid me over the annual sum insured (recurring payments for dialysis) I don't know why or how. But that's why we are decades old customers (full family) and I personally upgrade to their highest available tier whenever I can. I also always pay upfront and claim later because my choice of hospital stays the same (most reputed one in my area) but their contracts for cashless treatments with insurance companies keep changing over the years.

Lanky-Bottle-6566

The first thing I did when I got an insurance was to read the comprehensive brochure of my plan. It was about 16 pages long with legalese used everywhere. 

When we went for my father's gall bladder operation, every written thing was followed. There was a point where they said this operation could not be performed before 3 year from date of inception. Luckily 5 years had passed. But just imagine if 3 years hadn't passed we'd have thought the company is a scam. 

Don't wanna say that no company can be scam, but very few people actually read the terms and conditions after buying an insurance.

Ok_Moment4946

Miss-spotlight

Probably some online scammer company or even worse.. Star Health TPA.

hl2dumbass

people buy insurance on policy bazaar and other online sites, choosing the lowest quote without reading the fine print.

ashishahuja77

ZLancer5x5

yep, in almost all cases you'll have to go to court to get a justified compensation. Govt should penalize insurance companies with history of exploitation.

MynameisMynameis_

many hospitals refuse to accept particular insurances too  i faced issue with CARE .. you can visite any other hospital hopefully they dont have such stupid mou signed.

directdilse

for such issues where things are enforced without documentation, you can always raise complaints to IRDAI. first you need to warn them in a mail keeping esclating email id's , after couple of days just raise the issue with IRDAI keeping them in CC,  i have little hope on IRDAI with my first experience on vehicle insurance issuance issue.

Low-Poet-5312

Last year, my mother had to go through cataract surgery, for which the hospital quoted around Rs. 80,000, which included the lens of our choosing, which was a multifocal lens of highest quality they had ( thats why the high price of 80,000 for a catarct surgery). My father had corporate insurance of 5L and an addon of 10L, a total of 15L. But the insurance only provided around Rs.38,000 for the entire thing. The reasoning was something related to geographical location stating the average cost of cataract surgery was Rs.35,000 in my area.

Key_Cranberry3997

mumbaiblues

I have HDFC ergo and for me my insurance claim experience was good. I was admitted twice in Medanta and totally cashless not a single penny came out of my pocket.

EducationalDouble707

I had ICICI via amex, wife had a surgey, we choose robotic laproscopy, they asked clarification for robotic vs open, doctor wrote a justification note it got approved, well the doc is well know in robotic laproscopy so it needed to be approved somehow. Also covered all tests and medicines. Out of pocket was 12k max

hotcoolhot

People should seriously read the fine print before buying insurance.

thunderbird350xm

This year I've had two situations where I've had to use health insurance for surgeries - one for myself (employer provided insurance) and one for my mother (covered by my dad's employer). 

Both were cashless and the process and experience was seamless. I did not have to pay even a single paisa out of my pocket - not even for consumables. 

I think for most common surgeries, the insurance companies and hospitals agree upon a "package" price for the surgeries. So if your surgery is one of the common ones, then most likely you will get fully covered as long as you have adhered to your room rent caps. 

It's not all a scam I would say. I think we should be careful of what policies we buy and what the fine print says.

AccomplishedLynx773

First of all if nothing is mentioned about the capping in T&amp;C, file a case with IRDAI. Those two parties cannot bilaterally change the t&amp;c of the policy for which you are paying the premium(no MoU is valid). But do read the T&amp;C thoroughly once again and if you feel you are cheated file a case.

Ambitious_Hat_6767

TreacleOwn6364

Odd-Factor-4349

OP please share the insurance company name here, I also recently had an accident and I too have implants and used cashless. Didn't face what you are telling.

Balwant223

Op didn't even gave a thought to share insurance name. What's the point of sharing this then?

Power-of-Behnoi

Hi I am an insurance agent that specializes in health insurance. Your mistake is trusting third party brokers like policy bazaars. Second it seemed you weren't aware of your policy which is fine it's not expected unless you buy it from an IRDAI licenced agent like me. 

The TPA desk creates hassles for clients because they know they won't put up a fight. These MOUs means nothing to a client if you opt for imported implants you will get imported implants because what's important is the contract between you and the insurance company if there is no sublimit mentioned that means no sublimit exists for your implants you got tricked into it. I don't dismiss what happened to you but it's a job the agent to deal with these issues not the individual.

Don't buy from a third party without understanding your policy and buy from IRDAI licensed agents like me. 

PS: I specialize in health insurance and am happy to help anyone get the right policy.

ArabianCoconut

Ofc, they're a business not charity. Their only goal is to make money. We are moving towards American type of healthcare instead of universal healthcare. 

We are in a transition phase, where everyone will believe that insurance is better. Once they become a majority in our population, their colors will be revealed instantly. There's a reason why lot of Americans support Luigi Mangione.

_AkasunaNoSasori

pheklom

If you tech savvy upload insurance doc to chatgpt and ask questions and understand all clauses properly.

gajakesari

Port the insurance policy to different company

blueangel7784

Sounds very odd. 

Which hospital and which insurance ? 

There are procedure specific limits but never heard about constraints on implants, etc.

bhodrolok

TSMentDUKE

For an operation hospital quoted me 2.2 lacs, they had tie up with insurance co for 1.5 lac for same surgery. They did not charge me the extra as it is a negotiated rate for surgery and not part payment.

yadvindrian

My corporate insurance from Reliance covered the whole 3L for my surgeries last year, cashless. Always check the fine print, don’t just buy the cheapest plan you see online. Lots of them have certain diseases that aren’t covered or partly covered.

Inside_Assumption157

sharedevaaste

TraderBull007

crazymustang11

The conflict between hospitals and Star Health Insurance has escalated, with threats to suspend cashless services, impacting many policyholders.

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