Will the Settlement of Cashless Health Insurance Claims Improve in 2025-26?
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Synopsis
In a significant development, Finance Minister Nirmala Sitharaman has announced that the unresolved cashless health insurance claims have dropped to 0.39% for the first half of 2025-26, highlighting improvements in the resolution process. This positive trend is aligned with regulatory mandates aimed at enhancing the efficiency of health insurance claims.
Key Takeaways
- 0.39% of cashless health claims remain unresolved as of September 2025-26.
- 257,790 complaints were received in 2024-25, with 4,811 unresolved.
- Insurers must resolve complaints within 14 days.
- Timelines for cashless claims are one hour for authorization and three hours for discharge.
- IRDAI's integration of Bima Bharosa with CMS enhances real-time complaint tracking.
New Delhi, Dec 1 (NationPress) The proportion of complaints regarding cashless health claim settlements that remain unresolved by insurance companies has decreased to 0.39 percent of all complaints filed in the first half (April-September) of 2025-26, as reported by Finance Minister Nirmala Sitharaman in Parliament on Monday.
In response to a question in the Lok Sabha, the Finance Minister disclosed that throughout the financial year 2024-25, a total of 257,790 complaints were lodged on the Bima Bharosa platform, of which 4,811 complaints, equivalent to 1.87 percent, were not resolved in a timely manner.
For the ongoing year 2025-26, up until September 30, there have been 136,554 complaints submitted, with 532 complaints remaining unresolved within the designated timeframe, representing 0.39 percent of the total complaints.
The Insurance Regulatory and Development Authority of India (IRDAI) has mandated that insurers implement the necessary systems and procedures to adhere to the required timelines for cashless requests by July 31, 2024.
The specified timelines are one hour for initial authorization and three hours for final discharge approval regarding cashless health claim settlements.
Furthermore, the minister noted that the IRDAI has confirmed that the Bima Bharosa platform is connected to the Complaint Management Systems (CMS) of insurance companies. This ensures that complaints submitted via Bima Bharosa are updated in the insurers' CMS in real-time, and vice versa. Insurers are required to resolve complaints within a period of 14 days.
However, the Bima Bharosa system is not linked with the Insurance Ombudsman System, meaning there is no automatic escalation of complaints to the Ombudsman. Complainants who are dissatisfied with insurer resolutions can file a complaint with the Insurance Ombudsman in the relevant jurisdiction, either physically or electronically.
In the financial year 2024-25, 53,102 complaints were lodged with Insurance Ombudsman offices concerning insurers seeking relief.
The Finance Minister also indicated that eleven show-cause notices were issued during 2024-25 for violations related to health and policyholder regulations, including unwarranted claim deductions and improper claim denials.
Point of View
The reported decrease in unresolved cashless health insurance claims is a positive development. It reflects the government's efforts to enhance consumer protection and streamline the insurance process. However, the integration of the Bima Bharosa system with the Insurance Ombudsman remains a concern, highlighting the need for further improvements in complaint resolution mechanisms.
NationPress
01/12/2025
Frequently Asked Questions
What is the current percentage of unresolved cashless health claims?
As of the first half of 2025-26, the unresolved cashless health claims stand at 0.39% of total complaints.
What is the role of the Bima Bharosa platform?
The Bima Bharosa platform is designed to manage health insurance complaints, ensuring they are tracked and resolved in a timely manner.
How long do insurers have to resolve complaints?
Insurers are required to resolve complaints within 14 days as per the regulations set by the IRDAI.
Can I escalate my complaint to the Insurance Ombudsman?
Yes, if you are unsatisfied with the resolution provided by insurers, you can file a complaint with the Insurance Ombudsman.
What are the regulatory timelines for cashless health claims?
The regulatory timelines state that initial authorization should be completed within one hour, and final discharge approval within three hours.
