The General Insurance Council (GI Council) is exploring the creation of a structured insurer-hospital platform to resolve disputes over health insurance claims, cashless treatment and other operational issues. The proposed mechanism would have balanced representation from insurers and healthcare providers and is intended to enable faster resolution through dialogue rather than allowing disagreements to directly affect policyholders.
The initiative comes amid renewed friction between health insurers and hospitals over claim settlements, treatment protocols, hospital tariffs and medical documentation. Dr S. Prakash, CEO – Health Insurance Ecosystem & Strategic Partnerships at the General Insurance Council, said the Council has established regular roundtable discussions involving major hospital associations, insurance companies and industry bodies to address these issues collaboratively.
Structured Grievance Mechanism Under Consideration
According to Prakash, discussions during the past several months have focused on establishing a structured payer-provider grievance redressal framework for faster resolution of disputes between insurers and hospitals. The Council is also working on strengthening the common empanelment framework to simplify hospital onboarding by insurers and improve access to cashless healthcare for policyholders.
Monthly roundtables include representatives of hospital associations, insurers and industry organisations such as FICCI, NATHEALTH and CII. The GI Council is now examining the possibility of developing a neutral platform with balanced participation from both payers and healthcare providers.
Such a mechanism could be particularly important where disagreements arise over whether a particular treatment was medically necessary, whether documentation was adequate or whether the expenses claimed were admissible under an insurance policy.
Medical Advisory Panel Also Proposed
Hospitals have frequently raised concerns that doctors working for insurers or third-party administrators may question the clinical judgement of treating physicians when reviewing claims.
Prakash said claim decisions should be based on policy admissibility and supporting documentary evidence, but stressed that the clinical judgement of the treating doctor or specialist should remain central to treatment decisions. Clinical and technical claim reviews should therefore not override medical autonomy. At the same time, insurers require adequate clinical documentation and evidence-based assessment to ensure consistency and fairness in claims settlement.
To address complicated medical disagreements, the GI Council has proposed setting up a Medical Advisory Panel comprising specialists from different medical disciplines. The panel could provide clinical inputs in cases where expert medical assessment is required.
Fever Admission Advisory Triggered Fresh Concerns
Insurer-hospital relations again came under focus following a GI Council advisory issued in July 2026 concerning hospitalisation for fever and infectious diseases.
The advisory recommended outpatient management for uncomplicated cases while indicating hospitalisation for more serious conditions involving symptoms such as persistent high fever, dehydration or organ dysfunction. Some hospitals expressed concern that insurers might use these indicators to reject claims where discharge summaries did not explicitly record the specified symptoms.
The GI Council subsequently clarified that its advisory refers to existing guidelines issued by the Ministry of Health and Family Welfare and the Indian Council of Medical Research (ICMR) and is not intended to interfere with doctors’ clinical autonomy.
The episode demonstrates the need for clearer communication between hospitals and insurers when clinical guidance could potentially affect claim assessments.
Hospitals Asked to Improve Billing Transparency
The General Insurance Council is also seeking greater standardisation and transparency from healthcare providers.
Prakash said hospitals could contribute by adopting standardised tariffs, clearer billing practices and stronger Hospital Management Information Systems (HMIS). Better capture of healthcare data and monitoring of patient outcomes would also improve transparency across the ecosystem.
Greater consistency in treatment protocols and healthcare costs could help insurers assess claims more efficiently and may reduce disputes over billing and treatment.
The issue has become increasingly significant as medical inflation and rising healthcare expenses put pressure on both insurance premiums and claim costs.
Claim Rejections Can Affect Consumer Trust
Claim rejection and partial settlement remain important concerns among health insurance customers.
Prakash acknowledged that although most health insurance claims are settled successfully, rejected or partially settled claims can affect policyholder confidence. Such cases can arise because of policy exclusions, contractual conditions or incomplete documentation, highlighting the need for greater transparency and consumer understanding of insurance coverage.
Trust is especially important in health insurance because consumers frequently discover the practical limitations of their policies only when hospitalisation occurs.
The proposed insurer-hospital dispute-resolution mechanism could therefore have implications beyond institutional relations. Faster and more transparent resolution of disagreements could ultimately improve the claims experience for policyholders.
Premium Increases Also Under Scrutiny
Alongside claim settlement disputes, health insurance customers have raised concerns about substantial increases in renewal premiums. The ET interview noted cases where policyholders reported premium increases of 100–150%.
Prakash said premium revisions cannot be attributed solely to medical inflation. Pricing is influenced by several factors, including a product’s claims experience, incurred claims ratio, actuarial assessment and overall portfolio performance. Premium revisions are therefore product-specific, and some policyholders may experience changes while others may go several years without a revision.
The industry is conducting deeper analysis of medical inflation, including speciality-wise healthcare cost trends, to understand the factors driving treatment expenses. Insurers are also seeking efficiencies through common hospital empanelment, digital integration and closer collaboration with healthcare providers.
Case for a Healthcare Regulator
The GI Council has also supported greater transparency and consistency across the healthcare provider ecosystem.
Prakash noted that insurer claim-settlement information and performance metrics are already publicly available, while greater transparency is required on the healthcare-provider side. A dedicated healthcare regulatory framework could potentially bring greater consistency to hospital pricing, treatment protocols and operational practices.
For policyholders, such standardisation could help reduce uncertainty surrounding hospital charges and claim admissibility.
The broader direction being pursued by the GI Council therefore extends beyond resolving individual claims. It seeks to create a more coordinated health insurance ecosystem in which insurers, hospitals and medical professionals operate through clearer standards, stronger data systems and structured dispute-resolution mechanisms.
If implemented effectively, the proposed insurer-hospital panel and Medical Advisory Panel could help reduce institutional friction while ensuring that consumers are not caught between healthcare providers and insurers when disputes arise over treatment or claims.
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