The health insurer-hospital friction, that had peaked in September 2025 over cash less tariffs, is back in focus after the General Insurance Council (GI Council) issued an advisory in July recommending outpatient care for uncomplicated fever and infectious diseases, with hospitalisation reserved for patients showing symptoms such as persistent high fever, dehydration or or gan dysfunction. Hospitals fear insurers could use the advisory to deny claims if discharge summaries do not explicitly mention these red flags. The GI Council later clarified that the advisory merely references existing Ministry of Health and Family Welfare and Indian Council of Medical Research (ICMR) guidelines and does not constrain clinical autonomy. ET Wealth caught up with GI Council’s Dr S. Prakash to discuss the broader is sues that affect policyholders, including claim settlement and premium hikes.
It’s been over six months since you took charge. What are your objectives?
My primary objective is to strengthen collaboration across the health insurance ecosystem and create a platform where insurers, healthcare providers and indus try bodies can work together to address some of the challenges in the space. Over the past five months, we have established a regular roundtable advisory with major hospital associations, insurance companies and industry bodies. These discussions have fostered a collaborative approach to resolving issues that impact policyholders.
What points of friction have been taken up for discussion?
So far, the deliberations have touched upon the need for a structured payer provider (insurer-hospital) grievance re dressal framework to enable quicker reso lution through collaborative dialogue. Another focus area was strengthening the common empanelment framework to make it easier for insurers to onboard hos pitals and for policyholders to access cash less services. Greater standardisation in treatment workflows was also discussed.
Insurer-hospital disputes over cashless claims persist. What steps have been taken to prevent or reduce these?
Over the last few months, we have focused on strengthening dialogue across the health insurance ecosystem. A key step has been the monthly roundtable with representatives from major hospital as sociations, insurance companies and industry bodies such as the Federation of Indian Chambers of Commerce and Industry (FICCI), NATHEALTH (Healthcare Federation of India) and Confederation of Indian Industry (CII). We are also exploring a structured, neu tral platform with balanced representa tion from both payers and providers to facilitate constructive dialogue.
Hospitals say claim rejections are often arbitrary and that doctors employed by third-party administrators (TPAs) or insurers question the treating doctors’ judgment. How would you respond to this criticism?
Claims should be assessed based on poli cy admissibility and the supporting docu mentary evidence. However, the clinical judgment of the treating doctor or special ist should remain central to treatment decisions. While clinical reviews and technical assessments are an important part of the claims process, they should not override medical autonomy. At the same time, claims assessment also requires clinical documentation and evidence based evaluation to ensure consistency and fairness across the ecosystem. The GI Council has also proposed the creation of a Medical Advisory Panel comprising ex perts from different specialties to provide clinical inputs wherever required.
What steps do you want hospitals to take?
A key priority for the healthcare eco system should be greater standardisa tion and transparency. Hospitals can help by adopting standardised tariffs, clearer billing and stronger Hospital Management Information Systems (HMIS). Better data capture and monitor ing of patient outcomes are also needed.
Claim rejections and partial settlements continue to dominate policyholder complaints. Are you concerned these could erode trust in health insurance?
Trust is the foundation of health insur ance, so every policyholder concern deserves careful attention. While most health insurance claims are settled suc cessfully, instances of claim rejections or partial settlements can understandably impact customer confidence. Many such cases arise due to policy terms, exclusions or incomplete documentation, which also highlights the need for greater transpar ency and customer awareness.
Besides claim rejections, the steep rise in renewal premiums is another major concern among policyholders…
Rising healthcare costs and medical inflation are important considerations, but they are not the sole drivers of premium revisions. Premiums are determined by a combination of factors, including a prod uct’s claims experience, incurred claims ratio (ICR), actuarial assessment and over all product performance. As a result, pre mium revisions are product-specific, and while some policyholders may experience revisions, others may not see any change for several years. At the same time, greater standardisation across the healthcare eco system, including (at the hospitals’ end) more consistent treatment protocols and greater transparency in healthcare costs, can help improve claims experience and contribute to the long-term sustainability of health insurance products.
Many policyholders have seen renewal premiums jump 100-150%. Besides stand ardising healthcare costs, what solutions can the health insurance industry offer?
Addressing affordability requires a multi-pronged approach that goes beyond standardisation. The industry is under taking a deeper study of medical inflation, including speciality-wise cost trends, to better understand the underlying drivers of healthcare costs. Alongside this, the industry is focussing on improving opera tional efficiencies through initiatives such as common empanelment, greater digital integration and closer collaboration be tween insurers and healthcare providers.
How will the establishment of a health care regulator, if implemented, benefit the sector and customers?
Today, insurers’ claim settlement data and performance metrics are publicly available. There is also a need for greater transparency on the provider side. Such a framework (a dedicated healthcare regu lator) could help bring greater consistency in hospital pricing, treatment protocols, and operational practices, benefiting all stakeholders across the healthcare value chain.
