The government has clarified that there is no proposal to make insurers follow healthcare providers' opinion on health insurance claims, and health claims will continue to be decided according to insurance policy conditions, according to The Hindu BusinessLine and Asia Insurance Review reports on July 27.
Minister of State for Health and Family Welfare Prataprao Jadhav told Parliament on July 24 that IRDAI had informed the government that insurers assess claims based on the terms and conditions of the policy and the merits of each case. While the treating doctor's assessment is one of the factors considered during claim evaluation, insurers also consider clinical records, applicable medical standards and standard treatment protocols where available.
The statement came in response to a question about private insurers rejecting claims for hospital admissions recommended by specialist doctors on grounds such as non-medical necessity or exclusion, and whether national standard guidelines or a medical audit mechanism would be introduced.
Sources: The Hindu BusinessLine, Asia Insurance Review (July 27, 2026)