Council for Insurance coverage Ombudsmen (CIO) 2023-24 information reveals the 5 worst medical insurance firms in India based mostly on complaints and declare rejections.
Considered one of my shoppers just lately shared a video exhibiting complaints in opposition to medical insurance firms, based mostly on the Council for Insurance coverage Ombudsmen (CIO) 2023-24 information. I discovered it fascinating and determined to share it right here. Bear in mind, although, that is 2023-24 information, and we’re already in mid-2025, so its present relevance is unsure. Nonetheless, it affords helpful perception and some extent 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 popularity. I’m merely sharing data from the newest CIO report accessible, and readers can draw their very own conclusions about which firms carry out greatest or worst.
High 5 Well being Insurance coverage Corporations by Complaints – CIO Report
Medical health insurance is meant to offer 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 care for the payments. Sadly, the truth isn’t 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 have 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 high 5 insurers with the worst criticism information. This can aid you 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 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, exhibiting the federal government’s continued concentrate on defending customers.
The Council for Insurance coverage Ombudsmen (CIO) manages 17 ombudsman places of work throughout India. It contains 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 robust dedication to policyholders:
- 52,575 complaints obtained and 49,705 resolved in the course of the yr.
- This represents a 43% bounce in complaints resolved in comparison with 2022-23.
- 87% of circumstances have been settled inside 90 days of registration.
- Over 42% of complaints have 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 critical they’re about fast motion.
Digital Push for Sooner Resolutions
Earlier, submitting a criticism usually meant bodily paperwork and lengthy waits. Now, the CIO has taken an enormous digital leap to make the method easier and sooner:
- Almost 40% of complaints have been registered on-line in 2023-24.
- A good increased 72% of hearings have 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 frequent 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 know-how is making grievance redressal sooner and extra clear.
The Greatest Drawback: Declare Rejection
Essentially the most alarming a part of the 2023-24 report is the rationale behind complaints. A large 95% of medical insurance complaints have been as a result of insurers partially or utterly denied claims. That is stunning and divulges that declare repudiation is the only greatest 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 provides a number of strategies to enhance this case:
- 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 option to face a declare rejection later.
- Clear Clarification of Coverage Phrases: Insurers ought to clarify difficult clauses like “Affordable & Customary Fees” in easy language. Many individuals are unaware of those limits till their claims are lowered.
- Replace Guidelines for Fashionable Remedies: Medical science is evolving. Many surgical procedures now 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. This can forestall confusion when hospitals challenge separate payments.
- Fraud Management: To struggle pretend claims that increase everybody’s premiums, the Ombudsman recommends sharing fraud information throughout insurers, submitting police complaints when wanted, and blacklisting fraudulent hospitals.
High 5 Worst Well being Insurance coverage Corporations (Primarily based on 2023-24 CIO Report)
The CIO report additionally highlights which insurers obtained the most complaints and delays. This information is a goldmine for anybody looking for medical insurance. Beneath are the high 5 firms with the best variety of complaints and circumstances the place the Ombudsman dominated in opposition to them.
| Rank | Insurer | Complaints Obtained | 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 Obtained: 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 – Additionally they had the best variety of unresolved complaints on the finish of the monetary yr.
- Complaints Disposed Above 1 12 months: 1,828 – Worryingly, that is the best variety of complaints that took over a yr 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 circumstances, suggesting a excessive proportion of justified grievances from policyholders.
- Care Well being Ins. Ltd.
- Complaints Obtained: 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 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 Obtained: 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 12 months: 428 – A considerable variety of complaints took over a yr 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 have been made in opposition to this firm.
- Nationwide Insurance coverage Co. Ltd.
- Complaints Obtained: 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 circumstances took greater than a yr to conclude, indicating extended decision occasions.
- Awards & Suggestions in Favour of Complainant: 1,015 – The fourth-highest variety of opposed findings by the ombudsman have been in opposition to this firm.
- The New India Assurance Co. Ltd.
- Complaints Obtained: 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 on a yr 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 have been discovered in opposition to this insurer by the ombudsman.
These numbers present that each non-public and public sector insurers have critical service gaps, and policyholders ought to rigorously take into account 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 criticism information earlier than shopping for. You may entry these reviews on-line.
- Disclose every part truthfully when making use of for a coverage—well being situations, previous therapies, way of life habits.
- Learn coverage phrases rigorously. Perceive exclusions, room lease limits, and ready intervals.
- Declare rejected doesn’t imply insurer is unhealthy – We now have a standard notion to imagine 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 know what is roofed and what’s NOT.
Bear in mind, utmost good religion is a two-way road: you have to be truthful, and insurers have to be honest.
Methods to Battle Again if Your Declare Is Rejected
A declare rejection isn’t the top of the street. 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. Evaluate it together with your coverage wording to test for errors or misinterpretations. - Collect Sturdy Proof
Acquire each related doc: coverage schedule, proposal kind, premium receipts, hospital payments, diagnostic reviews, and all e mail or name information with the insurer or TPA. - Method 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 connect 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 displays 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 yr of the insurer’s last response.
Hearings might be digital, choices normally 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. Legal professionals are optionally available for smaller claims.
Professional Tricks to Keep away from Rejections Altogether
- Disclose all medical historical past truthfully.
- Perceive ready intervals and sub-limits earlier than signing.
- Use cashless community hospitals to scale back disputes.
- Preserve coverage particulars and speak to information up to date.
The Highway Forward
The CIO isn’t 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 Criticism Administration System for simpler entry.
- Launch a revamped web site for higher person expertise.
These steps will particularly profit well being policyholders as a result of medical insurance constantly generates the best variety of complaints.
Remaining Ideas
The Insurance coverage Ombudsman has turn into a strong 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 be a warning. Declare repudiation remains to be an enormous downside, and a few insurers repeatedly fail their clients. Earlier than shopping for or renewing your coverage, look past shiny brochures and low premiums. Examine the insurer’s criticism historical past, decision pace, and customer support monitor file.
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 information to choose 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.
