Lok Sabha Question No. 1007 (UNSTARRED), answered on 2025-07-25
Subject: Misconduct of Health Insurance Companies
Ministry: HEALTH AND FAMILY WELFARE
Asked by: Dr. Bachhav Shobha Dinesh

## GOVERNMENTOFINDIA MINISTRYOF HEALTH AND FAMILYWELFARE DEPARTMENTOFHEALTH ANDFAMILYWELFARE

## LOK SABHA UNSTARRED QUESTION NO. 1007 TO BE ANSWERED ON 25 TH JULY, 2025

## MISCONDUCTOFHEALTH INSURANCE COMPANIES

## 1007. DR. BACHHAV SHOBHADINESH:

Will the Minister of HEALTH AND FAMILY WELFARE be pleased to state:

- (a) whether the Government has taken cognizance of the misconduct of Health Insurance Companies towards medical practitioners to avoid settlement of claims, if so, details thereof;
- (b) whether the Government has instituted an enquiry to review complains of doctors and nurses regarding harassment faced by them from health insurance companies, if so, the details thereof and if not, the reasons therefor;
- (c) whether the Government has formulated any concrete policies to ensure protection of rights of the medical and healthcare workers of the country and if so, the details thereof; and
- (d) whether the Government plans to formulate and enact a comprehensive legislation with regards to regulating the conduct of health insurance companies, towards medical practitioners and if so, the details thereof?

## ANSWER THE MINISTER OF STATE IN THE MINISTRY OF HEALTH AND FAMILY WELFARE (SHRI PRATAPRAO JADHAV)

(a) to (d): No such complaints or information regarding misconduct by health insurance companies towards medical practitioners with the intent to avoid settlement of claims have been received by the National Health Authority (NHA).

As per Constitutional provisions, 'Health' and 'Law and Order' are State subjects. It is the primary responsibility of the concerned State/UT to take note of events and eventualities for taking appropriate action to prevent violence against medical professionals. Further, many States have enacted laws to address violence against medical professionals. Most of the State laws cover minor offences and prescribe punishment for them. Major offences / heinous crimes are adequately covered under Bharatiya Nyaya Sanhita (BNS), 2023.

Insurance Regulatory and Development Authority of India (IRDAI) has informed that in terms of Regulation 2(i) of the TPA Regulations 2016, it has mandated that the insurers and

TPAs shall enter into ' Health Services Agreement ' laying down the terms and conditions of services which may be rendered to the policyholders and may be entered into between:

-  a Third-Party Administrator (TPA) and an insurer; or
-  a Network provider and an insurer; or
-  a Network provider, a TPA and the insurer

The Health Services Agreements lay down the scope and obligations of each party to the agreement and the services are rendered as per the agreed clauses.

IRDAI has also issued Master Circular on IRDAI (TPA) Regulations 2016. As per the Master Circular, it is specified that the agreements entered into by insurers, TPAs and network providers, shall have Arbitration and Dispute Resolution clause. Therefore, any dispute/violation arising out of the operation of agreed clause is within the realm of the parties to resolve.

As regards to settlement of claims, it is submitted that the IRDAI has revamped health insurance framework and notified IRDAI (Insurance Products) -Regulations, 2024 and issued a Master Circular on Health Insurance Business in order to bring in more transparency and to improve the customer claim settlement experience among others. These steps are expected to result in better-informed policyholders, ensure transparency and efficiency in settlement of claims, reduced grievances, disputes and delays, and a seamless health insurance experience for policyholders.

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