A new study from healthcare provider Pristyn Care found that 5 out of 10 patients face delays in discharge due to the time taken to process medical insurance claims. To alleviate the hassle experienced by health insurance policyholders, the Insurance Regulatory and Development Authority of India (IRDAI) is likely to introduce a 100% cashless hospital network that will include both empanelled and non-empanelled hospitals.

The study indicates that over 40% of individuals attribute delays in health insurance claims in India to hospital administrative processes, while 25% cite a lack of coordination between hospitals and insurance providers. Complex documentation procedures also significantly contribute to these delays. Furthermore, the survey underscores various challenges encountered by patient families throughout the insurance claims process, with nearly 4 out of 10 respondents reporting difficulties with customer support regarding the claims process.

The study also found that 6 out of 10 individuals never initiated the health insurance claim process. Among those who did, 34% expressed dissatisfaction with the paperwork, while 40% faced challenges in receiving timely responses from their insurance providers. Roughly 3 out of 10 patients encountered discrepancies between pre-approved and final claim amounts. Additionally, around 38% of respondents reported that the discharge process took over 8 hours, with hospitals requiring a similar timeframe to process claims. Approximately 4 out of 10 individuals lacked clarity on their policy’s terms and conditions. Furthermore, about 18% expressed dissatisfaction with the communication received from their insurance providers regarding claim statuses.

Commenting on the findings, Dr. Vaibhav Kapoor, Co-founder of Pristyn Care, said, “There is a huge gap between the intended ease of cashless health insurance and the reality experienced by policyholders. Despite 75% of survey respondents having cashless insurance, a significant number still face challenges during the claim process. This creates additional stress for patients and families already dealing with a medical emergency. However, it’s encouraging to note that insurance providers have already started digitizing and using tech to make the process quick and smooth. By embracing technological innovations, insurance providers are not only addressing the current challenges faced by policyholders but also paving the way for a more efficient and customer-centric insurance ecosystem. As digitization continues to evolve, it holds the promise of further enhancing the accessibility and effectiveness of health insurance, ultimately benefiting patients and their families during times of medical need.

According to PwC, the use of AI and ML in claims processing can reduce processing time by upto 90%, a report said. 

A streamlined health insurance process is crucial. It eliminates the immediate financial burden of critical care, allowing patients and families to focus on recovery. Technology offers a powerful solution. Many insurance companies now provide user-friendly mobile applications for convenient policy management. Furthermore, advancements in artificial intelligence and machine learning are enabling insurers to process claims faster and with greater accuracy.”

According to a report from the Insurance Regulatory and Development Authority of India (IRDAI), currently, cashless settlement services are accessible in 49% of hospitals in India. Both general and health insurance companies update their roster of affiliated hospitals in response to costly medical bills and false claims aimed at increasing payouts from insurers. To address these challenges, the insurance regulator, in collaboration with the General Insurance Council, aims to establish a nationwide common cashless hospital network. This initiative aims to expand and streamline the health insurance claims settlement process.