Council for Insurance coverage Ombudsmen (CIO) 2023-24 knowledge reveals the 5 worst medical insurance corporations in India primarily based on complaints and declare rejections.
One in every of my purchasers not too long ago shared a video displaying complaints in opposition to medical insurance corporations, primarily based on the Council for Insurance coverage Ombudsmen (CIO) 2023-24 knowledge. I discovered it fascinating and determined to share it right here. Bear in mind, although, that is 2023-24 knowledge, and we’re already in mid-2025, so its present relevance is unsure. Nonetheless, it presents helpful perception and a degree of reference.
The current numbers could have modified. Some corporations could have improved, whereas others could not. This put up is not meant to wreck any insurer’s repute. I’m merely sharing data from the newest CIO report obtainable, and readers can draw their very own conclusions about which corporations carry out greatest or worst.
Prime 5 Well being Insurance coverage Corporations by Complaints – CIO Report
Medical health 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 handle the payments. Sadly, the fact will not be all the time so easy. 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 corporations: 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 grievance information. It will allow you to make an knowledgeable choice 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 beneath the Redressal of Public Grievances Guidelines to assist policyholders get justice with out going to court docket. Over time, the system has advanced. The most recent replace got here in November 2023, displaying the federal government’s continued concentrate on defending shoppers.
The Council for Insurance coverage Ombudsmen (CIO) manages 17 ombudsman places of work 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 shortly.
Key Achievements in 2023-24
The Ombudsman’s 2023-24 efficiency has been spectacular and reveals their robust dedication to policyholders:
- 52,575 complaints obtained and 49,705 resolved throughout the 12 months.
- This represents a 43% soar 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 by 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 reveals how critical they’re about fast motion.
Digital Push for Quicker Resolutions
Earlier, submitting a grievance typically meant bodily paperwork and lengthy waits. Now, the CIO has taken an enormous digital leap to make the method easier and sooner:
- Practically 40% of complaints had been registered on-line in 2023-24.
- A good larger 72% of hearings had been held on-line, saving time and journey prices.
- Awards at the moment are digitally signed, and you’ll 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 grievance.
Quickly, policyholders may also get real-time monitoring of complaints and automatic scheduling of hearings. This reveals how know-how is making grievance redressal sooner and extra clear.
The Largest Downside: Declare Rejection
Probably the most alarming a part of the 2023-24 report is the explanation behind complaints. A large 95% of medical insurance complaints had been as a result of insurers partially or utterly denied claims. That is stunning 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 ideas to enhance this example:
- Utmost Good Religion (Uberrima Fides): Insurance coverage relies on honesty from either side. Policyholders should disclose all well being particulars—previous diseases, therapies, and situations—when shopping for a coverage. Hiding info is a positive approach to face a declare rejection later.
- Clear Clarification of Coverage Phrases: Insurers ought to clarify sophisticated clauses like “Affordable & Customary Costs” in easy language. Many individuals are unaware of those limits till their claims are decreased.
- Replace Guidelines for Trendy Remedies: Medical science is evolving. Many surgical procedures now not want a full 24-hour hospital keep, however some insurers nonetheless reject claims primarily based 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 forestall confusion when hospitals concern separate payments.
- Fraud Management: To struggle faux claims that increase everybody’s premiums, the Ombudsman recommends sharing fraud knowledge throughout insurers, submitting police complaints when wanted, and blacklisting fraudulent hospitals.
Prime 5 Worst Well being Insurance coverage Corporations (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 purchasing for medical insurance. Beneath are the prime 5 corporations with the best variety of complaints and instances the place the Ombudsman dominated in opposition to them.
| Rank | Insurer | Complaints Acquired | Pending at Yr-Finish | Complaints Over 1 Yr | 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 Take a look at the Worst Performers
- Star Well being and Allied Ins. Co. Ltd.
- Complaints Acquired: 12,594 – That is by far the best variety of medical insurance complaints obtained by any insurer, signaling vital buyer dissatisfaction.
- Complaints Excellent: 1,828 – In addition they had the best variety of unresolved complaints on the finish of the monetary 12 months.
- Complaints Disposed Above 1 Yr: 1,828 – Worryingly, that is the 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 – They’d the third-highest variety of unresolved complaints.
- Complaints Disposed Above 1 Yr: 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 cases 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 – They’d the fourth-highest variety of unresolved complaints.
- Complaints Disposed Above 1 Yr: 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 suggestions 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 Yr: 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 grievance 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 Yr: 535 – They rank second in taking on 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 personal and public sector insurers have critical service gaps, and policyholders ought to fastidiously contemplate these information 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.
- Examine grievance information earlier than shopping for. You possibly can entry these reviews on-line.
- Disclose every thing actually when making use of for a coverage—well being situations, previous therapies, life-style habits.
- Learn coverage phrases fastidiously. Perceive exclusions, room hire limits, and ready durations.
- Declare rejected doesn’t imply insurer is unhealthy – We’ve got a typical notion to consider that if the corporate rejected the declare, then the corporate is unhealthy. Nevertheless, there are numerous causes for rejections, and lots of occasions, we, policyholders unable to know what is roofed and what’s NOT.
Bear in mind, utmost good religion is a two-way avenue: you have to be truthful, and insurers have to be honest.
How you can Combat 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. Determine the particular coverage clause cited. Examine it along with your coverage wording to examine for errors or misinterpretations. - Collect Sturdy Proof
Accumulate each related doc: coverage schedule, proposal kind, premium receipts, hospital payments, diagnostic reviews, and all electronic mail or name information with the insurer or TPA. - Strategy the Insurer’s Grievance Cell
Ship a written grievance to the corporate’s Grievance Redressal Officer. Quote your declare quantity, clarify why the rejection is unfair, and connect proof.
Timeline: Insurer should reply inside 15 days. - Escalate to IRDAI (IGMS)
If unhappy, register the grievance on the Built-in Grievance Administration System at igms.irda.gov.in or name 155255. IRDAI displays and nudges the insurer to resolve it. - File a Case with the Insurance coverage Ombudsman
If the insurer nonetheless fails, strategy the Ombudsman on-line at cioins.co.in inside one 12 months of the insurer’s closing response.
Hearings might be digital, selections normally come inside 90 days, and the award is binding on the insurer—and it’s free. - Shopper Court docket as a Final Resort
If all else fails, you may strategy the District, State, or Nationwide Shopper 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 actually.
- Perceive ready durations and sub-limits earlier than signing.
- Use cashless community hospitals to scale back disputes.
- Preserve coverage particulars and get in touch with information up to date.
The Highway Forward
The CIO will not be stopping right here. For 2024-25, they intention to:
- Get rid of complaints inside three months.
- Obtain 70% on-line grievance registration.
- Add new options to the Criticism 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 persistently generates the best variety of complaints.
Last Ideas
The Insurance coverage Ombudsman has turn into 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. Examine the insurer’s grievance historical past, decision velocity, and customer support monitor document.
Medical health insurance isn’t just 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.
