Health insurance complaints have been in the news lately — reports suggest around 4 in 10 claimants remain dissatisfied with their claim experience. At the same time, IRDAI has pushed through some genuinely useful reforms over the past two years that most policyholders don’t know they’re entitled to. If you’re buying a new policy or reviewing one at renewal, here’s what’s actually changed, and what’s worth checking before you sign.
Cashless Everywhere: no longer limited to network hospitals
Under IRDAI’s 2024 Master Circular, cashless treatment is no longer restricted to hospitals empanelled with your insurer. Under the “Cashless Everywhere” reform, you can seek cashless treatment at any hospital, not just those on your insurer’s network list, provided you follow your insurer’s intimation timelines and documentation requirements. This is a meaningful change from the older system, where going out-of-network usually meant paying upfront and claiming reimbursement later.
Firm timelines, with a financial penalty for insurers who miss them
IRDAI’s rules set clear turnaround times that every insurer must meet: cashless pre-authorisation must be decided within one hour of a complete request from the hospital, and final discharge approval within three hours. For reimbursement claims, insurers must decide within 30 days of receiving your last document — not from your date of discharge. If an insurer breaches these timelines, they’re liable to pay 2% above the bank rate as interest on the claim amount for every day of delay. It’s worth knowing these numbers specifically, since being able to cite the rule yourself is often what gets a stalled claim moving.
Insurer scorecards are coming — use them once available
From June 2026, IRDAI has been rolling out performance scorecards that measure claim settlement speed and accuracy for insurers, alongside billing standards for hospitals, with hospital payments eventually intended to be linked to performance. The framework is still being phased in, so exact published metrics may evolve, but the direction is clear: an insurer’s actual claim-settlement track record is becoming a visible, comparable number rather than just a marketing claim. When these scorecards are fully available, weigh them alongside premium when choosing or renewing a policy.
What to actually check before buying
A few things matter more than the headline premium:
- Claim Settlement Ratio (CSR): the percentage of claims an insurer has actually settled in a given year. A consistently high CSR across recent years is a stronger signal than a single good year.
- Room rent limits and sub-limits: many policies cap what they’ll pay toward room rent or specific procedures as a percentage of the sum insured — a low sub-limit can leave you paying a large out-of-pocket difference even with a seemingly generous cover amount.
- Co-payment clauses: some policies, especially those for senior citizens, require you to pay a fixed percentage of every claim yourself. Know this figure before you buy, not when you’re filing a claim.
- Waiting periods: for pre-existing conditions and specific treatments, waiting periods vary by insurer and product — check these against your own health situation rather than assuming a standard figure.
- AYUSH coverage: IRDAI’s reforms have expanded coverage for Ayurveda, Yoga, Unani, Siddha and Homeopathy treatments; if this matters to you, confirm the specific inclusions rather than assuming all AYUSH treatment is covered equally.
- Portability rights: you can switch insurers at renewal without losing benefits already earned (such as waiting periods already served), so being unhappy with your current insurer’s service doesn’t mean losing your accumulated benefits.
The bottom line
Health insurance in India has genuinely gotten more policyholder-friendly on paper over the last two years — the challenge is that most people don’t know these protections exist, so they don’t use them when a claim gets delayed or an insurer drags its feet. Before your next purchase or renewal, check the CSR, read the sub-limits and co-pay clauses carefully, and keep IRDAI’s timelines in mind if you ever need to push back on a delayed claim.
Related reading: health insurance: what you need to know, and life insurance: what you need to know.
