Council for Insurance coverage Ombudsmen (CIO) 2023-24 knowledge reveals the 5 worst medical insurance corporations in India primarily based on complaints and declare rejections.
One among my shoppers just lately shared a video exhibiting complaints in opposition to medical insurance corporations, primarily based on the Council for Insurance coverage Ombudsmen (CIO) 2023-24 knowledge. I discovered it attention-grabbing and determined to share it right here. Bear in mind, although, that is 2023-24 knowledge, and we’re already in mid-2025, so its present relevance is unsure. Nonetheless, it affords helpful perception and some extent of reference.
The current numbers could have modified. Some corporations could have improved, whereas others could not. This publish is not meant to wreck any insurer’s repute. I’m merely sharing info from the newest CIO report out there, and readers can draw their very own conclusions about which corporations carry out greatest or worst.
Prime 5 Well being Insurance coverage Corporations by Complaints – CIO Report
Medical 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 care for the payments. Sadly, the fact is just not all the time so clean. 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 in opposition to 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 determination 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 courtroom. Over time, the system has advanced. The most recent replace got here in November 2023, exhibiting the federal government’s continued give attention to defending shoppers.
The Council for Insurance coverage Ombudsmen (CIO) manages 17 ombudsman places of work 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 robust dedication to policyholders:
- 52,575 complaints acquired and 49,705 resolved through the 12 months.
- This represents a 43% bounce 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 by means of 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 severe they’re about fast motion.
Digital Push for Quicker Resolutions
Earlier, submitting a criticism typically meant bodily paperwork and lengthy waits. Now, the CIO has taken an enormous digital leap to make the method less complicated and sooner:
- Practically 40% of complaints had been registered on-line in 2023-24.
- A good greater 72% of hearings had been held on-line, saving time and journey prices.
- Awards are actually digitally signed, and you’ll 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 widespread 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 expertise 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 largest ache level for policyholders.
Why Do Insurers Reject Claims?
- Non-disclosure of pre-existing situations.
- 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 example:
- Utmost Good Religion (Uberrima Fides): Insurance coverage is predicated on honesty from each side. Policyholders should disclose all well being particulars—previous diseases, remedies, and situations—when shopping for a coverage. Hiding details is a certain solution to face a declare rejection later.
- Clear Clarification of Coverage Phrases: Insurers ought to clarify difficult clauses like “Cheap & Customary Prices” in easy language. Many individuals are unaware of those limits till their claims are decreased.
- Replace Guidelines for Fashionable Therapies: Medical science is evolving. Many surgical procedures now not want a full 24-hour hospital keep, however some insurers nonetheless reject claims primarily based on outdated 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 lined. This may stop confusion when hospitals situation separate payments.
- Fraud Management: To struggle faux claims that increase everybody’s premiums, the Ombudsman recommends sharing fraud knowledge throughout insurers, submitting police complaints when wanted, and blacklisting fraudulent hospitals.
Prime 5 Worst Well being Insurance coverage Corporations (Primarily based on 2023-24 CIO Report)
The CIO report additionally highlights which insurers acquired the most complaints and delays. This knowledge is a goldmine for anybody searching for medical insurance. Under are the prime 5 corporations with the very best variety of complaints and circumstances the place the Ombudsman dominated in opposition to them.
| Rank | Insurer | Complaints Obtained | 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 Obtained: 12,594 – That is by far the very best variety of medical insurance complaints acquired by any insurer, signaling important buyer dissatisfaction.
- Complaints Excellent: 1,828 – Additionally they had the very 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 very 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 Obtained: 3,419 – This firm acquired the second-highest quantity of medical insurance complaints.
- Complaints Excellent: 291 – That they had 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 situations the place the ombudsman dominated in opposition to the corporate.
- NIVA BUPA HEALTH INSURANCE CO.LTD
- Complaints Obtained: 2,399 – This firm acquired the third-highest variety of medical insurance complaints.
- Complaints Excellent: 287 – That they had 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 important 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 in opposition to this firm.
- Nationwide Insurance coverage Co. Ltd.
- Complaints Obtained: 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 hostile findings by the ombudsman had been in opposition to this firm.
- The New India Assurance Co. Ltd.
- Complaints Obtained: 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 on 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 in opposition to this insurer by the ombudsman.
These numbers present that each non-public and public sector insurers have severe service gaps, and policyholders ought to fastidiously take into account these information earlier than shopping for.
Classes for Policyholders
The information 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 may entry these experiences on-line.
- Disclose all the things actually when making use of for a coverage—well being situations, previous remedies, life-style habits.
- Learn coverage phrases fastidiously. Perceive exclusions, room hire limits, and ready durations.
- Declare rejected doesn’t imply insurer is dangerous – We now have a typical notion to consider that if the corporate rejected the declare, then the corporate is dangerous. Nonetheless, there are numerous causes for rejections, and lots of occasions, we, policyholders unable to grasp 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 truthful.
Learn how to Battle 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 particular coverage clause cited. Evaluate it together with your coverage wording to examine for errors or misinterpretations. - Collect Robust Proof
Acquire each related doc: coverage schedule, proposal type, premium receipts, hospital payments, diagnostic experiences, and all e-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 connect 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, method the Ombudsman on-line at cioins.co.in inside one 12 months of the insurer’s ultimate response.
Hearings may be digital, selections 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 method the District, State, or Nationwide Client Fee (relying on declare quantity) inside two years of the dispute. Attorneys are optionally available for smaller claims.
Professional Tricks to Keep away from Rejections Altogether
- Disclose all medical historical past actually.
- Perceive ready durations and sub-limits earlier than signing.
- Use cashless community hospitals to cut back disputes.
- Maintain coverage particulars and call data up to date.
The Highway Forward
The CIO is just not stopping right here. For 2024-25, they goal 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 very best variety of complaints.
Last Ideas
The Insurance coverage Ombudsman has change into a robust 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 be a warning. Declare repudiation remains to be an enormous drawback, and a few insurers repeatedly fail their prospects. Earlier than shopping for or renewing your coverage, look past shiny brochures and low premiums. Research the insurer’s criticism historical past, decision velocity, and customer support observe document.
Medical insurance is not only about paying a premium; it’s about belief that your insurer will stand by you in powerful occasions. Use this knowledge 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.
