Council for Insurance coverage Ombudsmen (CIO) 2023-24 information reveals the 5 worst medical insurance corporations in India primarily based on complaints and declare rejections.
One in all my shoppers lately shared a video exhibiting complaints towards medical insurance corporations, primarily based 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 presents helpful perception and a degree of reference.
The current numbers could have modified. Some corporations could have improved, whereas others could not. This submit is not meant to break any insurer’s fame. I’m merely sharing data from the most recent CIO report obtainable, and readers can draw their very own conclusions about which corporations carry out finest or worst.
High 5 Well being Insurance coverage Firms by Complaints – CIO Report
Medical health insurance is meant to present 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 deal with the payments. Sadly, the truth will not be at all times so easy. 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 corporations: 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 acquired towards insurers and the way they had been resolved.
On this article, we’ll stroll you thru the highlights of the Annual Report 2023-24, clarify the developments behind medical insurance complaints, and reveal the prime 5 insurers with the worst criticism information. This may aid you make an knowledgeable resolution 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 court docket. Over time, the system has developed. The most recent replace got here in November 2023, exhibiting the federal government’s continued give attention to defending customers.
The Council for Insurance coverage Ombudsmen (CIO) manages 17 ombudsman workplaces 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 sturdy dedication to policyholders:
- 52,575 complaints acquired and 49,705 resolved through the 12 months.
- This represents a 43% leap in complaints resolved in comparison with 2022-23.
- 87% of circumstances had been settled inside 90 days of registration.
- Over 42% of complaints had 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 Quicker Resolutions
Earlier, submitting a criticism usually meant bodily paperwork and lengthy waits. Now, the CIO has taken a giant digital leap to make the method easier and sooner:
- Practically 40% of complaints had been registered on-line in 2023-24.
- An excellent larger 72% of hearings had 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 will 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 Largest Drawback: Declare Rejection
Essentially the most alarming a part of the 2023-24 report is the explanation behind complaints. An enormous 95% of medical insurance complaints had been as a result of insurers partially or utterly denied claims. That is surprising and divulges that declare repudiation is the only greatest ache level for policyholders.
Why Do Insurers Reject Claims?
- Non-disclosure of pre-existing circumstances.
- Misunderstanding or miscommunication about coverage protection.
- Insurers sticking to outdated guidelines about hospitalization or procedures.
Ombudsman Suggestions
The report provides a number of ideas to enhance this case:
- Utmost Good Religion (Uberrima Fides): Insurance coverage is predicated on honesty from each side. Policyholders should disclose all well being particulars—previous diseases, therapies, and circumstances—when shopping for a coverage. Hiding details is a certain technique to face a declare rejection later.
- Clear Clarification of Coverage Phrases: Insurers ought to clarify sophisticated clauses like “Affordable & Customary Costs” in easy language. Many individuals are unaware of those limits till their claims are decreased.
- Replace Guidelines for Trendy Therapies: Medical science is evolving. Many surgical procedures not want a full 24-hour hospital keep, however some insurers nonetheless reject claims primarily based 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 coated. This may forestall confusion when hospitals challenge separate payments.
- Fraud Management: To combat 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 Firms (Based mostly on 2023-24 CIO Report)
The CIO report additionally highlights which insurers acquired the most complaints and delays. This information is a goldmine for anybody searching for medical insurance. Beneath are the prime 5 corporations with the best variety of complaints and circumstances the place the Ombudsman dominated towards them.
| Rank | Insurer | Complaints Acquired | Pending at 12 months-Finish | Complaints Over 1 12 months | Ombudsman Dominated In opposition to |
| 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 Acquired: 12,594 – That is by far the best variety of medical insurance complaints acquired by any insurer, signaling vital buyer dissatisfaction.
- Complaints Excellent: 1,828 – In addition they had the best variety of unresolved complaints on the finish of the monetary 12 months.
- Complaints Disposed Above 1 12 months: 1,828 – Worryingly, that is the best variety of complaints that took over a 12 months 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 Acquired: 3,419 – This firm acquired 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 acquired and excellent complaints signifies broader points of their service.
- Awards & Suggestions in Favour of Complainant: 1,687 – That is the second-highest variety of cases the place the ombudsman dominated towards the corporate.
- NIVA BUPA HEALTH INSURANCE CO.LTD
- Complaints Acquired: 2,399 – This firm acquired 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 12 months 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 had been made towards this firm.
- Nationwide Insurance coverage Co. Ltd.
- Complaints Acquired: 1,923 – This public sector insurer acquired 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 12 months to conclude, indicating extended decision occasions.
- Awards & Suggestions in Favour of Complainant: 1,015 – The fourth-highest variety of opposed findings by the ombudsman had been towards this firm.
- The New India Assurance Co. Ltd.
- Complaints Acquired: 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 big backlog of unresolved points.
- Complaints Disposed Above 1 12 months: 535 – They rank second in taking up a 12 months 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 had been discovered towards this insurer by the ombudsman.
These numbers present that each personal and public sector insurers have critical service gaps, and policyholders ought to fastidiously think about these information earlier than shopping for.
Classes for Policyholders
The info 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’ll be able to entry these experiences on-line.
- Disclose every part actually when making use of for a coverage—well being circumstances, previous therapies, life-style habits.
- Learn coverage phrases fastidiously. Perceive exclusions, room hire 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. Nevertheless, 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.
The right way to Combat 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 precise coverage clause cited. Evaluate it along with your coverage wording to examine for errors or misinterpretations. - Collect Robust Proof
Accumulate each related doc: coverage schedule, proposal kind, premium receipts, hospital payments, diagnostic experiences, and all electronic 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 fix 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 screens and nudges the insurer to resolve it. - File a Case with the Insurance coverage Ombudsman
If the insurer nonetheless fails, strategy the Ombudsman on-line at cioins.co.in inside one 12 months of the insurer’s remaining response.
Hearings may be digital, choices often 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 strategy the District, State, or Nationwide Client Fee (relying on declare quantity) inside two years of the dispute. Legal professionals are non-compulsory for smaller claims.
Professional Tricks to Keep away from Rejections Altogether
- Disclose all medical historical past actually.
- Perceive ready intervals and sub-limits earlier than signing.
- Use cashless community hospitals to cut back disputes.
- Hold coverage particulars and speak to information up to date.
The Highway Forward
The CIO will not be stopping right here. For 2024-25, they purpose to:
- Eliminate 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 out to be 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 also be a warning. Declare repudiation remains to be an enormous downside, and a few insurers repeatedly fail their prospects. 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 observe report.
Medical health insurance is not only 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 actually deserves it.
