Health insurance claims in India will continue to be assessed by insurers according to policy terms, with the government ruling out any proposal to make the treating healthcare provider’s opinion binding on claim decisions. The clarification was given in the Lok Sabha on July 24, 2026.
The government said insurers consider several factors while evaluating claims, including clinical records, the treating doctor’s assessment, applicable medical standards, standard treatment protocols and the specific terms and conditions of the insurance policy. A doctor’s opinion therefore forms part of the assessment but does not automatically determine whether a claim must be accepted.
The parliamentary response also highlighted a gap in regulatory data. The Insurance Regulatory and Development Authority of India (IRDAI) collects overall claim repudiation information but does not maintain insurer-wise data explaining the specific reasons for individual claim rejections, such as exclusions or lack of medical necessity.
IRDAI’s 2024-25 annual data showed that insurers processed about 3.26 crore health insurance claims during the financial year. Around 87% were settled, 8% were repudiated and approximately 5% remained pending at the end of the year.
The clarification reinforces that health insurance claims remain contractual decisions governed by policy coverage, exclusions and medical evidence rather than solely by the recommendation of the treating hospital or doctor.
