Lok Sabha Question No. 20 (STARRED), answered on 2025-12-01
Subject: Insurance Claim Settlement
Ministry: FINANCE
Asked by: Shri Sribharat Mathukumilli

## GOVERNMENT OF INDIA MINISTRY OF FINANCE DEPARTMENT OF FINANCIAL SERVICES

## LOK SABHA

## STARRED QUESTION NO. *20

ANSWERED ON MONDAY, 01 st  DECEMBER, 2025/AGRAHAYANA 10, 1947 (SAKA)

## Insurance Claim Settlement

*20. SHRI SRIBHARAT MATHUKUMILLI:

- Will the Minister of FINANCE be pleased to state: (a)  the  total  number  of  instances  of  delayed  cashless  claim  settlements,  wherein  the mandatory timelines of one hour for initial authorisation and three hours for final discharge approval were breached by Insurance companies since the implementation deadline of the Insurance Regulatory and Development Authority of India (IRDAI) Master Circular on Health Insurance Business 2024; (b) the number of cases till date by which insurers failed to provide final resolution within the mandated fifteen days from receipt of grievance; (c)  the  number  of  grievances  filed  on  the  Bima  Bharosa  platform  that  were  deemed unsatisfactory by policyholders and subsequently escalated to the Insurance Ombudsman for review; and (d) the number of Show Cause Notices formally issued till date to Insurance companies for
- contraventions relating to unnecessary claim deductions and improper claim rejections?

## ANSWER

THE FINANCE MINISTER (SMT. NIRMALA SITHARAMAN)

- (a) to (d): A Statement is laid on the Table of the House.

*****

STATEMENT  AS  REFERRED  TO  IN  REPLY  TO  PART  (A)  TO  (D)  OF  LOK  SABHA STARRED QUESTION NO. *20 FOR 01 st , DECEMBER, 2025/ AGRAHAYANA 10, 1947 (SAKA) REGARDING 'INSURANCE CLAIM SETTLEMENT' RAISED BY SHRI SRIBHARAT MATHUKUMILLI, HON'BLE MEMBER OF PARLIAMENT

(a): As per the provisions of Insurance Regulatory and Development Authority of India (IRDAI) Master Circular on Health Insurance Business dated 29.05.2024, insurers were required to put in place the necessary systems and procedures to adhere to the mandated timelines for cashless requests by 31 st  July 2024. The one hour and three hour cashless authorisation timelines were made effective from 1 st  August 2024. The data on compliance of cashless settlement, as reported by IRDAI for 1 st  August 2024 to 31 st  May 2025 is as per Annexure-I.

(b) and (c): IRDAI has informed that Bima Bharosa platform is integrated with the Complaint Management Systems (CMS) of the Insurers. Thus, the complaints filed in Bima Bharosa are reflected in CMS of the insurers on real time basis and vice versa. A time period of 14 days has been specified within which an insurer is required to resolve complaints.

- During the financial year 2024-25, total 2,57,790 complaints were received in Bima Bharosa portal, out of which, for 4,811 complaints, the insurers have not provided the resolution within the stipulated time, constituting 1.87 percent of the total complaints received during the year.
- During the current year 2025-26 (up to 30 th  Sept, 2025), total 1,36,554 complaints were received, out of which, for 532 complaints, the insurers have not provided the resolution within the stipulated time, constituting 0.39 percent of the total complaints received.

IRDAI  has  further  informed  that  Bima  Bharosa  system  is  not  integrated  with  Insurance Ombudsman System and there is no provision in Bima Bharosa to escalate the complaints automatically  to  Insurance  Ombudsman.  However,  a  complainant  not  satisfied  with  the resolution  provided  by  the  insurers,  has  an  option  to  file  complaint  with  Insurance Ombudsman having competent jurisdiction. Such complaint can be filed either in physical mode or through electronic mode.

During financial year 2024-25, 53,102 complaints have been filed with Insurance Ombudsman offices against the insurers seeking relief.

(d): Eleven Show Cause Notices were issued during 2024-25 on violations relating to Health and Policyholders related regulatory provisions including unnecessary claim deductions and improper claim rejections.

*****

## Annexure I referred to in reply to Lok Sabha Starred Question No. *20 for 01.12.2025

## Data on Cashless pre-authorization

| Time                     | Number of Cashless Requests processed for pre-authorisation   | %of Cases   |
|--------------------------|---------------------------------------------------------------|-------------|
| Within 1 hour            | 55,35,353                                                     | 86.88%      |
| >1 hours and <= 2 hours  | 5,40,941                                                      | 8.49%       |
| > 2 hours and <= 5 hours | 1,98,367                                                      | 3.11%       |
| > 5 hours                | 96,959                                                        | 1.52%       |
| Total                    | 63,71,620                                                     | 100%        |

## Data on final cashless authorization

| Time                     | Number of Cashless Requests processed for final authorisation   | %of Cases   |
|--------------------------|-----------------------------------------------------------------|-------------|
| Within 3 hours           | 54,92,758                                                       | 96.69%      |
| >3 hours and <= 4 hours  | 92,667                                                          | 1.63%       |
| > 4 hours and <= 8 hours | 51,737                                                          | 0.91%       |
| > 8 hours                | 43,836                                                          | 0.77%       |
| Total                    | 56,80,998                                                       | 100%        |