Health Claim Rejection Data India: What FY25 Numbers Say

Quick answer: In FY2024-25, Indian insurers handled about 3.26 crore health claims. Roughly 87% were settled, 8% were repudiated (no payment), and about 5% were still pending at year end, according to figures drawn from IRDAI's Annual Report 2024-25. So most claims get paid, but about one in twelve does not, and a settled claim is not always paid in full.

The numbers, in plain terms

The headline figures reported from IRDAI's Annual Report 2024-25 are these: 3.26 crore health claims, about Rs 94,247 crore paid out, 87% settled, 8% repudiated and around 5% pending. Business Standard quoted IRDAI Chairman Ajay Seth saying that claim numbers are high but "the amount settled, especially in full, is sometimes lower than expected", and that the regulator is monitoring the gap.

That last point matters more than the 87%. "Settled" means the insurer paid something. It does not mean the hospital bill was cleared. Deductions for non-payable items, room-rent limits and co-payment all produce partial settlements that still count as settled.

Complaint data points the same way. The Bima Bharosa portal logged 2,57,790 grievances in FY25, up about 20% from 2,15,569 the year before, and roughly 69% of general and health insurance grievances were about claims. Insurance Ombudsman offices received 53,184 complaints, with health disputes making up about 64% of them; reports say around 71% were resolved in the policyholder's favour. Treat those last percentages as reported figures, not audited ones.

What nobody can tell you: why claims are rejected

You might expect IRDAI to publish a breakdown of rejection reasons. It does not, at least not in a form anyone can use. In a Lok Sabha reply on 24 July, the government said IRDAI holds no data on why health claims are denied; the regulator collects overall repudiation rates, not reasons per claim, and there is no insurer-wise split by grounds such as exclusions or "not medically necessary".

So any article that tells you "the top reason for rejection is X, with Y%" is either quoting one insurer's marketing material or guessing. What we can say comes from the policy wording and from complaint patterns: waiting periods, undisclosed pre-existing conditions, excluded procedures, missing documents and late intimation are the usual suspects. Our page on claim rejection goes through each.

Claim settlement ratio vs incurred claims ratio

These two are constantly confused, and comparison sites often put them side by side as if they measure the same thing.

• Claim settlement ratio (CSR) is a count-based measure: how many claims received were settled. IRDAI's annual report publishes it for life insurers' individual death claims. For FY25, Table I.11 shows 10,34,455 individual death claims, of which 10,11,880 (97.82%) were paid, 1.01% repudiated, 0.66% rejected and 0.48% pending at year end.
• Incurred claims ratio (ICR) is a financial measure: claims incurred divided by premium earned. A high ICR says the insurer pays out a large share of premium as claims; it says nothing about how many individual claims it turns down or how cleanly it pays them.

Neither number tells you how your claim will go. A 98% settlement ratio is an average across millions of policies, most of which never had a problem. A very high ICR can also mean the insurer is under financial strain, which is why a higher figure is not automatically better.

A practical checklist before you buy or renew

• Read the sub-limits first. Room-rent caps, disease-wise limits and co-payment clauses cause more partial payments than outright rejections. See room rent limits and co-payment.
• Declare pre-existing conditions fully. Non-disclosure is a classic ground for repudiation. Know your waiting periods and the moratorium rule, under which claims on a policy that has completed 60 months of continuous cover cannot be contested for non-disclosure, except for proven fraud.
• Check the list of non-payable items. Gloves, admission charges and similar consumables are often excluded unless you have a consumables benefit.
• Keep documents ready. Discharge summary, itemised bills, investigation reports and prescriptions. Missing papers cause avoidable delays.
• Prefer network hospitals for planned treatment. IRDAI's 2024 master circular on health insurance asks insurers to decide on cashless authorisation within one hour of the request and on final discharge within three hours. Confirm the current text on irdai.gov.in, as circulars get amended.

If your claim is rejected or under-paid

Do not accept a vague rejection. Ask for the reason in writing, with the exact clause relied on. Then escalate in order: the insurer's grievance officer, the IRDAI Bima Bharosa portal, and the Insurance Ombudsman. Under the Insurance Ombudsman Rules, 2017 you generally approach the ombudsman after the insurer has rejected your complaint or not replied within 30 days, and within one year of the insurer's reply. The ombudsman's award limit is Rs 30 lakh per claim. Rules and limits can change, so verify on the official Ombudsman portal before filing. Beware of lookalike complaint sites: IRDAI recently warned that a site called igmsirdai.online is not an official platform.

Frequently asked questions

Does an 87% settlement rate mean I have an 87% chance of being paid?

Not really. It is an industry-wide average, and the 8% repudiated group is concentrated among claims with documentation, disclosure or exclusion problems. A well-documented claim for a covered condition has better odds than the average suggests, but the data cannot tell us by how much.

Is "settled" the same as "paid in full"?

No. A claim can be settled after deductions. The IRDAI Chairman has himself noted that amounts settled can be lower than expected.

Which insurer has the lowest rejection rate?

We will not name one. Insurer-wise reasons are not published, and a single year's ratio is a weak guide. Compare policy wording and complaint records instead.

Can an insurer reject a claim after years of paying premiums?

Under the 60-month moratorium for health policies, claims cannot be contested on non-disclosure after continuous cover of 60 months, except fraud. Exclusions and waiting periods still apply.

Is the incurred claims ratio a good way to pick an insurer?

Use it with caution. It reflects the insurer's finances, not your claim experience.

Where can I read the official data?

The IRDAI Annual Report 2024-25 on irdai.gov.in. Note that the health claims tables are in section I.6.5 of the report; check them directly rather than relying on summaries, including this one.

Sources: IRDAI Annual Report 2024-25 (individual death-claim figures, Table I.11); Business Standard reporting of IRDAI Chairman Ajay Seth's remarks on claim settlement gaps; Insurance Business Asia reporting on the Lok Sabha reply of 24 July and Bima Bharosa and Ombudsman complaint data; Algates Insurance summary of the annual report for the health claim split. We could not independently open the health-claims tables of the report, so the 87/8/5 split and complaint percentages are as reported by these secondary sources. This is educational content, not insurance advice. See our editorial and trust policies and the health insurance hub and glossary for definitions.