The Centre has confirmed there is no proposal under consideration to require health insurers to give overriding precedence to the clinical opinion of treating doctors while deciding health insurance claims. According to reports from The Hindu BusinessLine, Minister of State for Health and Family Welfare Prataprao Jadhav made this statement in response to questions in the Lok Sabha on Friday. The government's position comes after concerns were raised about private health insurance companies rejecting claims for hospital admissions recommended by specialist doctors.
As reported by The Hindu BusinessLine, the Insurance Regulatory and Development Authority of India (IRDAI) has informed the government that insurers assess claims based on the terms and conditions of the policy and the merits of each individual case. According to the government's response, insurers consider clinical records, the assessment of the treating medical practitioner, applicable medical standards, standard treatment protocols, wherever available, and the policy conditions while determining their contractual liability under a health insurance policy. The government emphasized that while the treating doctor's assessment is one of the factors considered during claim evaluation, there is no proposal before the IRDAI to give the doctor's clinical opinion overriding authority.
According to the government's response reported by The Hindu BusinessLine, the IRDAI currently collects data only on the overall repudiation of health insurance claims by insurers. The government stated it does not maintain claim rejection data classified under specific reasons such as 'non-medical necessity' or 'exclusion'. As a result, insurer-wise data on claims rejected specifically on these grounds during the last three years is not available, the government informed Parliament.
The questions were posed by Lok Sabha MP from Samajwadi Party Devesh Shakya, who also asked whether the government planned to introduce national standard guidelines or a medical audit mechanism to prevent insurers from interfering with doctors' clinical discretion. However, as reported by The Hindu BusinessLine, there was no response to this question. Instead, the government reiterated that insurers follow existing policy conditions, medical records, treatment protocols and clinical assessments while processing claims.
