India is not considering any proposal requiring health insurers to accept the opinion of hospitals or other healthcare providers while deciding insurance claims.
Health insurance claims will continue to be assessed by insurers according to the terms and conditions of the policy purchased by the customer. This means that a hospital’s recommendation or medical opinion will not automatically determine whether a claim is approved or rejected.
While healthcare providers are responsible for diagnosing patients, recommending treatment and submitting the necessary medical records, insurers must examine whether the treatment and expenses are covered under the applicable policy.
The claim decision may therefore depend on factors such as the policy’s coverage, exclusions, waiting periods, sub-limits, deductibles, disclosure of pre-existing conditions and the medical necessity of the treatment.
The position preserves the insurer’s role in claim adjudication rather than transferring the final decision to hospitals. However, insurers are expected to provide proper reasons when claims are rejected or only partly approved.
Policyholders should carefully review their policy documents and submit complete medical records, bills, prescriptions and discharge summaries. Where a claim is considered unfairly rejected, customers can approach the insurer’s grievance redressal mechanism, the Insurance Ombudsman or the appropriate consumer forum.
The clarification highlights the distinction between a healthcare provider’s clinical opinion and an insurer’s contractual responsibility under the insurance policy.
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