India is not considering any proposal to make insurers follow healthcare providers’ opinion on health insurance claims and health insurance claims will continue to be decided according to insurance policy conditions.
According to Indian financial daily, The Hindu Businessline, Indian Minister of State for Health and Family Welfare Mr Prataprao Jadhav told the Indian parliament on 24 July 2026 that the Indian insurance regulator Insurance Regulatory and Development Authority of India (IRDAI) had informed that insurers assess claims based on the terms and conditions of the policy and the merits of each individual case.
The government said that while the treating doctor’s assessment is one of the factors considered during claim evaluation, there is no proposal to give the doctor’s clinical opinion overriding authority in deciding insurance claim liability.
Mr Jadhav said 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 statement was made in response to a member’s question if it was aware of instances where private health insurance companies had rejected claims for hospital admissions recommended by specialist doctors on grounds such as “non-medical necessity” or “exclusion”, allegedly affecting patients’ treatment.
The member 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.
