Council for Insurance coverage Ombudsmen (CIO) 2023-24 knowledge reveals the 5 worst medical insurance firms in India based mostly on complaints and declare rejections.
Certainly one of my purchasers not too long ago shared a video displaying complaints in opposition to medical insurance firms, based mostly on the Council for Insurance coverage Ombudsmen (CIO) 2023-24 knowledge. I discovered it fascinating and determined to share it right here. Keep in mind, although, that is 2023-24 knowledge, and we’re already in mid-2025, so its present relevance is unsure. Nonetheless, it affords helpful perception and a degree of reference.
The current numbers could have modified. Some firms could have improved, whereas others could not. This put up is not meant to break any insurer’s status. I’m merely sharing data from the most recent CIO report out there, and readers can draw their very own conclusions about which firms carry out finest or worst.
High 5 Well being Insurance coverage Firms by Complaints – CIO Report
Medical insurance is meant to present you monetary peace when a medical emergency strikes. We purchase a coverage in order that if we face a sudden sickness, surgical procedure, or hospital keep, the insurer will deal with the payments. Sadly, the fact shouldn’t be at all times so clean. Many individuals face issues like declare rejections, lengthy delays, and complicated paperwork, turning a well being disaster right into a nightmare.
The excellent news is that you’re not alone when this occurs. India has a devoted system to assist policyholders resolve disputes with insurance coverage firms: the Insurance coverage Ombudsman, managed by the Council for Insurance coverage Ombudsmen (CIO). Yearly, the CIO releases an in depth report in regards to the complaints obtained in opposition to insurers and the way they had been resolved.
On this article, we are going to stroll you thru the highlights of the Annual Report 2023-24, clarify the tendencies behind medical insurance complaints, and reveal the prime 5 insurers with the worst criticism data. It will provide help to make an knowledgeable determination when shopping for or renewing your medical insurance coverage.
What Is the Insurance coverage Ombudsman and Why It Issues
The Insurance coverage Ombudsman is sort of a referee between you and your insurance coverage firm. It was arrange in 1998 underneath the Redressal of Public Grievances Guidelines to assist policyholders get justice with out going to courtroom. Through the years, the system has advanced. The newest replace got here in November 2023, displaying the federal government’s continued deal with defending customers.
The Council for Insurance coverage Ombudsmen (CIO) manages 17 ombudsman workplaces throughout India. It consists of senior members from the insurance coverage and finance sectors, such because the Chairperson of LIC and representatives from IRDAI. Their job is to make sure that buyer complaints are dealt with pretty and rapidly.
Key Achievements in 2023-24
The Ombudsman’s 2023-24 efficiency has been spectacular and exhibits their sturdy dedication to policyholders:
- 52,575 complaints obtained and 49,705 resolved through the 12 months.
- This represents a 43% bounce in complaints resolved in comparison with 2022-23.
- 87% of instances had been settled inside 90 days of registration.
- Over 42% of complaints had been solved via mediation, which means each events agreed on a good settlement with out lengthy authorized battles.
9 out of seventeen centres even managed to clear all pending complaints by March 31, 2024—an enormous success that exhibits how severe they’re about fast motion.
Digital Push for Quicker Resolutions
Earlier, submitting a criticism typically meant bodily paperwork and lengthy waits. Now, the CIO has taken an enormous digital leap to make the method less complicated and sooner:
- Almost 40% of complaints had been registered on-line in 2023-24.
- A good greater 72% of hearings had been held on-line, saving time and journey prices.
- Awards at the moment are digitally signed, and you may securely obtain them utilizing an OTP.
- SMS alerts and auto-mailers replace complainants about each stage of their case.
- A chatbot named “Bima Lokpal Mitra” solutions widespread questions and guides you thru the method of submitting a criticism.
Quickly, policyholders may even get real-time monitoring of complaints and automatic scheduling of hearings. This exhibits how expertise is making grievance redressal sooner and extra clear.
The Greatest Downside: Declare Rejection
Essentially the most alarming a part of the 2023-24 report is the rationale behind complaints. An enormous 95% of medical insurance complaints had been as a result of insurers partially or utterly denied claims. That is surprising and divulges that declare repudiation is the one largest ache level for policyholders.
Why Do Insurers Reject Claims?
- Non-disclosure of pre-existing situations.
- Misunderstanding or miscommunication about coverage protection.
- Insurers sticking to outdated guidelines about hospitalization or procedures.
Ombudsman Suggestions
The report offers a number of solutions to enhance this case:
- Utmost Good Religion (Uberrima Fides): Insurance coverage is predicated on honesty from each side. Policyholders should disclose all well being particulars—previous sicknesses, therapies, and situations—when shopping for a coverage. Hiding information is a positive option to face a declare rejection later.
- Clear Clarification of Coverage Phrases: Insurers ought to clarify sophisticated clauses like “Affordable & Customary Expenses” in easy language. Many individuals are unaware of those limits till their claims are lowered.
- Replace Guidelines for Trendy Therapies: Medical science is evolving. Many surgical procedures not want a full 24-hour hospital keep, however some insurers nonetheless reject claims based mostly on previous necessities. The Ombudsman urges them to replace their insurance policies.
- Clear Specialist Charges: Insurance policies should clearly point out whether or not charges charged by specialists or surgeons throughout hospitalization are lined. It will stop confusion when hospitals subject separate payments.
- Fraud Management: To battle faux claims that increase everybody’s premiums, the Ombudsman recommends sharing fraud knowledge throughout insurers, submitting police complaints when wanted, and blacklisting fraudulent hospitals.
High 5 Worst Well being Insurance coverage Firms (Based mostly on 2023-24 CIO Report)
The CIO report additionally highlights which insurers obtained the most complaints and delays. This knowledge is a goldmine for anybody looking for medical insurance. Beneath are the prime 5 firms with the very best variety of complaints and instances the place the Ombudsman dominated in opposition to them.
| Rank | Insurer | Complaints Acquired | Pending at 12 months-Finish | Complaints Over 1 12 months | Ombudsman Dominated Towards |
| 1 | Star Well being & Allied Insurance coverage | 12,594 | 1,828 | 1,828 | 7,506 |
| 2 | Care Well being Insurance coverage | 3,419 | 291 | 13 | 1,687 |
| 3 | Niva Bupa Well being Insurance coverage | 2,399 | 287 | 428 | 1,297 |
| 4 | Nationwide Insurance coverage Co. | 1,923 | 283 | 165 | 1,015 |
| 5 | New India Assurance | 1,300 | 592 | 535 | 530 |
Detailed Have a look at the Worst Performers
- Star Well being and Allied Ins. Co. Ltd.
- Complaints Acquired: 12,594 – That is by far the very best variety of medical insurance complaints obtained by any insurer, signaling vital buyer dissatisfaction.
- Complaints Excellent: 1,828 – In addition they had the very best variety of unresolved complaints on the finish of the monetary 12 months.
- Complaints Disposed Above 1 12 months: 1,828 – Worryingly, that is the very best variety of complaints that took over a 12 months to resolve, indicating extreme operational delays.
- Awards & Suggestions in Favour of Complainant: 7,506 – The ombudsman discovered this firm at fault within the highest variety of instances, suggesting a excessive proportion of justified grievances from policyholders.
- Care Well being Ins. Ltd.
- Complaints Acquired: 3,419 – This firm obtained the second-highest quantity of medical insurance complaints.
- Complaints Excellent: 291 – That they had the third-highest variety of unresolved complaints.
- Complaints Disposed Above 1 12 months: 13 – Whereas this particular quantity is decrease in comparison with some others, the general excessive quantity of obtained and excellent complaints signifies broader points of their service.
- Awards & Suggestions in Favour of Complainant: 1,687 – That is the second-highest variety of situations the place the ombudsman dominated in opposition to the corporate.
- NIVA BUPA HEALTH INSURANCE CO.LTD
- Complaints Acquired: 2,399 – This firm obtained the third-highest variety of medical insurance complaints.
- Complaints Excellent: 287 – That they had the fourth-highest variety of unresolved complaints.
- Complaints Disposed Above 1 12 months: 428 – A considerable variety of complaints took over a 12 months to resolve, highlighting vital delays of their decision course of.
- Awards & Suggestions in Favour of Complainant: 1,297 – The third-highest variety of awards and proposals had been made in opposition to this firm.
- Nationwide Insurance coverage Co. Ltd.
- Complaints Acquired: 1,923 – This public sector insurer obtained the fifth-highest variety of medical insurance complaints.
- Complaints Excellent: 283 – They recorded the fifth-highest variety of excellent complaints.
- Complaints Disposed Above 1 12 months: 165 – A notable variety of instances took greater than a 12 months to conclude, indicating extended decision occasions.
- Awards & Suggestions in Favour of Complainant: 1,015 – The fourth-highest variety of opposed findings by the ombudsman had been in opposition to this firm.
- The New India Assurance Co. Ltd.
- Complaints Acquired: 1,300 – Whereas decrease than the highest, this nonetheless locations them among the many excessive criticism getters for medical insurance.
- Complaints Excellent: 592 – That is the second-highest variety of excellent complaints, indicating a major backlog of unresolved points.
- Complaints Disposed Above 1 12 months: 535 – They rank second in taking up a 12 months to resolve complaints, pointing to extreme delays of their decision course of.
- Awards & Suggestions in Favour of Complainant: 530 – A substantial variety of justified complaints had been discovered in opposition to this insurer by the ombudsman.
These numbers present that each non-public and public sector insurers have severe service gaps, and policyholders ought to rigorously contemplate these data earlier than shopping for.
Classes for Policyholders
The information sends a robust message to all of us:
- Don’t be blinded by low premiums. A less expensive coverage means nothing if the corporate delays or denies claims.
- Test criticism data earlier than shopping for. You possibly can entry these experiences on-line.
- Disclose all the pieces truthfully when making use of for a coverage—well being situations, previous therapies, life-style habits.
- Learn coverage phrases rigorously. Perceive exclusions, room lease limits, and ready durations.
- Declare rejected doesn’t imply insurer is unhealthy – We now have a standard notion to consider that if the corporate rejected the declare, then the corporate is unhealthy. Nonetheless, there are numerous causes for rejections, and plenty of occasions, we, policyholders unable to grasp what is roofed and what’s NOT.
Keep in mind, utmost good religion is a two-way road: you have to be truthful, and insurers have to be honest.
Find out how to Struggle Again if Your Declare Is Rejected
A declare rejection isn’t the tip of the highway. Right here’s a clear, step-by-step motion plan that can assist you problem a denial:
- Perceive the Rejection Letter
Learn it line by line. Establish the particular coverage clause cited. Evaluate it along with your coverage wording to test for errors or misinterpretations. - Collect Robust Proof
Accumulate each related doc: coverage schedule, proposal kind, premium receipts, hospital payments, diagnostic experiences, and all e-mail or name data with the insurer or TPA. - Strategy the Insurer’s Grievance Cell
Ship a written criticism to the corporate’s Grievance Redressal Officer. Quote your declare quantity, clarify why the rejection is unfair, and fix proof.
Timeline: Insurer should reply inside 15 days. - Escalate to IRDAI (IGMS)
If unhappy, register the criticism on the Built-in Grievance Administration System at igms.irda.gov.in or name 155255. IRDAI screens and nudges the insurer to resolve it. - File a Case with the Insurance coverage Ombudsman
If the insurer nonetheless fails, method the Ombudsman on-line at cioins.co.in inside one 12 months of the insurer’s ultimate response.
Hearings will be digital, selections often come inside 90 days, and the award is binding on the insurer—and it’s free. - Client Courtroom as a Final Resort
If all else fails, you possibly can method the District, State, or Nationwide Client Fee (relying on declare quantity) inside two years of the dispute. Attorneys are optionally available for smaller claims.
Professional Tricks to Keep away from Rejections Altogether
- Disclose all medical historical past truthfully.
- Perceive ready durations and sub-limits earlier than signing.
- Use cashless community hospitals to cut back disputes.
- Preserve coverage particulars and make contact with data up to date.
The Street Forward
The CIO shouldn’t be stopping right here. For 2024-25, they purpose to:
- Get rid of complaints inside three months.
- Obtain 70% on-line criticism registration.
- Add new options to the Grievance Administration System for simpler entry.
- Launch a revamped web site for higher consumer expertise.
These steps will particularly profit well being policyholders as a result of medical insurance constantly generates the very best variety of complaints.
Closing Ideas
The Insurance coverage Ombudsman has grow to be a robust ally for policyholders. With sooner resolutions, digital processes, and public reporting, they’re pushing insurers to be extra accountable.
However the 2023-24 report can also be a warning. Declare repudiation remains to be an enormous drawback, and a few insurers repeatedly fail their prospects. Earlier than shopping for or renewing your coverage, look past shiny brochures and low premiums. Research the insurer’s criticism historical past, decision velocity, and customer support monitor file.
Medical insurance is not only about paying a premium; it’s about belief that your insurer will stand by you in powerful occasions. Use this knowledge to select an organization that values that belief as a lot as you do.
Keep knowledgeable, keep wholesome, and ensure your Bima Bharosa (insurance coverage belief) is with an organization that really deserves it.
