5 out of 10 patients face discharge delays due to lengthy medi insurance claims processes

Pristyn Care study reveals challenges in health insurance claims processing, prompting calls for improved efficiency and digitization in the sector

New Delhi: A recent study conducted in all metro cities and 10 tier 2 cities on individuals aged between 18 to 65 years by healthcare provider Pristyn Care has shed light on the significant delays patients face in hospital discharge procedures due to lengthy medical insurance claim processing times.
According to the study, 5 out of 10 patients encounter discharge delays due to the time taken to process their medical insurance claims.
In response to these findings, the Insurance Regulatory and Development Authority of India (IRDAI) in collaboration with the General Insurance Council is reportedly considering the introduction of a 100% cashless hospital network, where presently only 49% of hospitals have access to such a system. This network would encompass both empanelled and non-empanelled hospitals, aiming to simplify the claims settlement process for health insurance policyholders.
The study, which surveyed over 4000 respondents across various cities in India, highlighted several key challenges encountered by individuals throughout the health insurance claims process. Among these challenges, over 40% of respondents attributed delays in claims processing to hospital administrative processes, while 25% cited a lack of coordination between hospitals and insurance providers. Complex documentation procedures were also identified as a significant contributing factor to delays. Furthermore, the study revealed that a substantial number of individuals faced difficulties with customer support regarding the claims process, with nearly 4 out of 10 respondents reporting such challenges. 
Additionally, 6 out of 10 individuals admitted to never initiating the health insurance claim process, pointing to a widespread issue of underutilization of health insurance benefits. Among those who did attempt to claim, 34% expressed dissatisfaction with cumbersome paperwork, while 40% encountered delays in receiving timely responses from their insurance providers. Furthermore, nearly one-third of patients experienced discrepancies between the initially approved claim amounts and the final settlements. The discharge process proved to be another bottleneck, with approximately 38% reporting wait times exceeding 8 hours, mirroring the duration hospitals took to process claims. Additionally, 4 out of 10 individuals admitted to lacking clarity on their policy’s terms and conditions, indicating a need for improved transparency. Alarmingly, 18% expressed dissatisfaction with the communication received from insurers regarding claim statuses, highlighting the need for enhanced customer service in the insurance sector.
Commenting on the findings, Dr. Vaibhav Kapoor, Co-founder of Pristyn Care, emphasized “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,” Dr Kapoor added.