A STUDY ON CHALLENGES IN HEALTH INSURANCE CLAIM SETTLEMENT IN INDIA

Abstract

The health insurance sector is a cornerstone of India’s efforts to provide accessible and affordable healthcare to its citizens. However, a critical area of concern remains the settlement of health insurance claims, which often involves procedural complexities, delays, and rejections. These challenges undermine policyholder confidence and impede the effectiveness of the health insurance ecosystem This study critically examines the issues faced in the claim settlement process by collecting primary data directly from individuals who have filed health insurance claims across both public and private sector insurance providers in India, focusing on constructs such as claim settlement efficiency, transparency, customer service responsiveness, documentation and procedural clarity, perceived fairness, and trust in insurers. The primary objectives are to assess policyholders’ satisfaction levels, identify major obstacles in claim approval and reimbursement, evaluate the influence of communication and documentation requirements on perceptions, and propose strategies to enhance efficiency and fairness. The need for this research arises from the widening gap between the expansion of health insurance coverage and persistent grievances related to delays, rejections, and lack of procedural transparency, with the scope encompassing diverse policyholders across multiple insurers and policy types. The research adopts a descriptive and analytical design, employing a structured questionnaire for primary data collection and supported by secondary sources from industry reports and regulatory publications. Statistical techniques such as descriptive statistics, correlation analysis, and multiple regression will be applied to analyze relationships between constructs and test the formulated hypotheses. Anticipated findings are expected to reveal systemic inefficiencies, inadequate communication, and misinterpretation of policy clauses, which undermine consumer confidence. The outcomes will benefit policyholders through improved claim processing, insurers through enhanced trust and retention, and policymakers by identifying regulatory gaps for targeted intervention.