Protect Your Team from Health Insurance Claim Rejections

Health insurance is a crucial financial safeguard when it comes to mitigating the high cost of healthcare and what good is it if the claims do not get approved when needed the most. Whether you are buying a health insurance policy for yourself or for your team, you should know about the latest insights released from the Council of Insurance Ombudsman report, which identifies the top 5 insurance providers that don’t make good on their promise to serve you in your time of need and have recorded the highest numbers of claims-related complaints against them.

Coincidentally, IRDAI also reported that health insurance claims worth Rs. 26,000 crores were disallowed and “repudiated” by insurers in the year ending March 2024, representing a 19.10% rise from Rs. 21,861 crores that were rejected in the year 2023. This showcased an alarming trend of high claim rejections in the health insurance sector.

However, health insurance is not an avoidable clause when it comes to employee benefits, it’s the core strategy for most businesses in India today. And for individuals, it’s the only reliable fail-safe against critical illnesses and medical emergencies. The idea of bringing this update to you is not to deter you from buying health insurance, but to help you dive deeper into the insights from the Insurance Ombudsman report, what to look for when buying a health insurance policy, and why choosing the right insurance provider is key to raising claims that don’t get denied.

The Role of IRDAI and Insurance Ombudsman in Facilitating a Smoother Claims Framework

The Insurance Regulatory and Development Authority of India (IRDAI) is the apex body overseeing India’s insurance sector. Its mandate is to protect policyholder interests, regulate insurers, and ensure fair practices. 

The Insurance Ombudsman, on the other hand, is an external, government-backed body that policyholders can approach if their grievances remain unresolved. It offers a free, impartial platform to address issues like claim denials, delays, or mis-selling, without the need for lengthy legal battles. 

Together, IRDAI’s regulatory oversight and the Ombudsman’s dispute resolution mechanism create a two-tier safety net, helping both individuals and businesses secure fair outcomes, reduce claim disputes, and build greater trust in the health insurance system. 

Also read: Top 10 Health Insurance Companies

5 Health Insurance Providers with the Highest Claim-Related Complaints

Here are the 5 worst health insurance providers that have received the maximum complaints from policyholders according to the Insurance Ombudsman report for the FY 2024:

1. Star Health & Allied Insurance Co. Ltd. 

• Total complaints: 13,308 

• Of which claim rejections: 10,196 

• Complaints per lakh policyholders: 63 

• Why it matters: Star Health’s complaint volume is more than the combined total of the next four insurers on this list. Nearly 90% of its business is retail, which means more direct consumer interactions — and disputes. 

2. CARE Health Insurance 

• Total complaints: 3,718 

• Of which claim rejections: 2,393 

• Complaints per lakh policyholders: 16 

• Why it matters: A significant number of grievances stem from partial or complete claim repudiations, highlighting the need for clearer communication on policy terms. 

3. Niva Bupa Health Insurance 

• Total complaints: 2,511 

• Of which claim rejections: 1,770 

• Complaints per lakh policyholders: 17 

• Why it matters: While smaller in scale than Star Health, Niva Bupa’s complaints-per-lakh ratio is still high, signalling potential service or claims process gaps. 

4. National Insurance Co. Ltd. (Public Sector) 

• Total complaints: 2,196 

• Complaints per lakh policyholders: 5 

• Why it matters: As a PSU, National Insurance has a lower complaint rate than private peers, but the absolute numbers still place it in the top five. 

5. The New India Assurance Co. Ltd. (Public Sector) 

• Total complaints: 1,602 

• Complaints per lakh policyholders: 1 

• Why it matters: Lowest complaint rate in the top five, but its inclusion shows that even large, established insurers face customer dissatisfaction. 

Quick read: What is No Claim Bonus in Health Insurance?

Key Factors to Consider While Choosing a Health Insurance Provider

1. Claim Settlement Ratio (CSR) 

• Indicates the percentage of claims an insurer settles in a year. 

• A higher CSR (above 95%) generally means better reliability. 

• Also check claim repudiation rates from Ombudsman reports to spot red flags.

2. Complaints Record & Ombudsman Data 

• Look at the number of complaints per lakh policyholders, not just total complaints. 

• High volume of complaints, specially for claim rejections, can signal service issues. 

3. Network Hospitals 

• A wide, well-distributed network ensures easier access to cashless treatment. 

• Check if your preferred hospitals are in-network. 

4. Coverage & Benefits 

• Adequate sum insured for your city’s healthcare costs. 

• Inclusion of pre- and post-hospitalisation expenses, day-care procedures, ambulance cover, and critical illness benefits. 

• For employers: ensure coverage suits the demographic and health profile of your workforce. 

5. Waiting Periods & Exclusions

• Waiting periods for pre-existing diseases, maternity, and specific treatments. 

• Permanent exclusions (e.g., cosmetic surgery, certain chronic conditions). 

• Shorter waiting periods = faster access to benefits. 

6. Premium vs. Value 

• Compare premiums against coverage, benefits, and service quality. 

• Avoid choosing solely on the lowest price — poor service can cost more in the long run. 

7. Claim Process Efficiency 

• Simplicity and speed of cashless and reimbursement claims. 

• Availability of 24×7 claims assistance. 

• Digital-first processes can reduce delays. 

8. Renewal Terms

• Lifetime renewability is a must. 

• Check if premiums increase sharply after claims (claim-based loading). 

9. Customer Support & Transparency 

• Responsiveness of helplines and grievance redressal teams. 

• Clarity in policy wording — no hidden clauses. 

Health Insurance Preparedness Checklist 

1. Before Buying or Renewing a Policy 

For Employees & Individuals 

• Disclose all health conditions honestly – Even minor or past illnesses; non-disclosure is a top reason for claim rejection.

• Understand waiting periods – For pre-existing diseases, maternity, and specific treatments.

• Read the exclusions list – Know what’s not covered before you need it.

• Check the insurer’s track record – Look at complaints per lakh policyholders, not just claim settlement ratio.

• Verify network hospitals – Ensure your preferred hospitals are in-network for cashless treatment.

For HR & Benefits Managers 

• Vet insurers beyond premiums: Compare complaint ratios, claim repudiation rates, and service quality.

• Negotiate shorter waiting periods: Especially for pre-existing conditions in group plans.

• Ensure coverage matches workforce needs: Age, family size, and health profile.

• Review policy exclusions: Avoid plans with restrictive clauses that could hurt employees.

• Check network hospital spread: Across all office locations and employee hometowns.

2. While the Policy is Active 

For Employees & Individuals 

• Pay premiums on time – Avoid policy lapses.

• Update personal details – Address, contact, and nominee information.

• Maintain health records – Keep prescriptions, test reports, and discharge summaries handy.

• Use preventive benefits – Health check-ups, wellness programs, or teleconsultations.

For HR & Benefits Managers 

• Ensure timely premium payments – Avoid coverage gaps for employees.

• Run awareness sessions – Educate employees on claims processes and benefits.

• Monitor claim trends – Spot patterns in rejections or delays early.

• Offer claims assistance – Have a dedicated SPOC or partner (like Onsurity) to guide employees.

3. When Filing a Claim 

For Employees & Individuals 

• Inform the insurer promptly – Pre-approval for planned hospitalisations; quick intimation for emergencies.

• Use network hospitals – For faster cashless claims.

• Submit complete documentation – Bills, prescriptions, ID proofs, and claim forms.

• Track claim status – Keep a record of all communications.

For HR & Benefits Managers 

• Support employees with documentation – Especially for reimbursement claims.

• Coordinate with insurer TPA – To expedite approvals.

• Escalate delays – Use internal grievance channels before going external.

4. If a Claim is Rejected 

For Employees & Individuals 

• Ask for a written explanation – Understand the exact reason.

• Escalate internally – Use the insurer’s grievance redressal process.

• Approach the Insurance Ombudsman – If unresolved within 30 days.

For HR & Benefits Managers 

• Review rejection reasons – Identify if policy terms or insurer service is the issue.

• Advocate for employees – Escalate with insurer relationship managers.

• Reassess insurer choice – If rejection patterns persist.

Onsurity’s Good Doctors Team: Your Claims Ally 

At Onsurity, we know that the real test of any health insurance plan comes when you need to file a claim. That’s why our Good Doctors Team is more than just a support desk — they’re your personal claims champions. 

Here’s how they make sure your claims are filed successfully and stress-free: 

• Pre-Claim Guidance – Helping members understand eligibility, required documents, and the right process before hospitalisation. 

• Document Verification – Reviewing bills, prescriptions, and forms to ensure nothing is missing that could delay or derail approval. 

• Cashless Coordination – Liaising directly with network hospitals and the insurer’s TPA to speed up approvals. 

• Real-Time Updates – Keeping you informed at every stage, so you’re never left wondering about your claim status. 

• Dispute Support – If a claim is queried or partially settled, the team steps in to clarify, escalate, and push for fair resolution. 

Why it matters: For employees, it means peace of mind during a health crisis. For HR teams, it means fewer escalations, happier employees, and a benefits program that truly delivers when it counts. 

Conclusion: Claims Rejection Is Not an Option

Health insurance is more than just a policy—it’s a promise. But as the latest Ombudsman data shows, that promise can fall short if you choose the wrong partner or overlook the fine print. For individuals, a rejected claim can mean financial strain and emotional stress. For employers, it can erode employee trust and undermine the very benefits meant to protect them. 

The good news? Most claim rejections are preventable with the right awareness, proactive planning, and a partner who truly has your back. At Onsurity, our Good Doctors Team ensures members aren’t left to navigate the claims maze alone. From pre-claim guidance to real-time hospital coordination and dispute support, we make sure your claims are filed right the first time and fought for if needed. 

We Partner With The Very Best To Deliver The Best For Your Team 

As a health and wellness benefits platform, we ensure thorough diligence is carried out to bring you offerings from some of the best providers in the industry. As per the Insurance Ombudsman report, our health insurance partners have a combined total of less than 1,000 claim-related complaints. This not only brings relief to us but also an added layer of assurance for you and your team.  

Because when it comes to your health and your team’s wellbeing, denial is not an option. Choose transparency, choose support, choose a partner who stands with you when it matters most. 

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