Health insurance in India is regulated by IRDAI (Insurance Regulatory and Development Authority of India). As a policyholder (or an IT/admin team managing employee benefits), you should know:
Which insurers are legally allowed to sell health insurance in India.
How insurers and intermediaries are registered and what compliance norms apply.
How to select and buy a policy based on underwriting/coverage grounds.
How claims work end-to-end (cashless vs reimbursement), timelines, and common rejection reasons.
This article is written as a practical knowledge base with implementable checklists and workflows.
In India, health insurance is typically offered by these IRDAI-registered entity types:
Standalone Health Insurers (SAHI)
These companies primarily sell health insurance. IRDAI publishes the official list.
General Insurers (Non-life insurers)
These companies sell multiple non-life products (motor, property, travel, health, etc.). IRDAI publishes the official list.
Life Insurers (limited health cover as riders / specific life products)
Life insurers may provide health-related riders/benefits depending on product design. IRDAI publishes the official list.
Below are health insurers listed by IRDAI (verify current status on IRDAI before onboarding).
+----+-------------------------------------------+-----------------------------------------------+
| # | IRDAI-listed Standalone Health Insurer | Website (as listed/known) |
+----+-------------------------------------------+-----------------------------------------------+
| 1 | Aditya Birla Health Insurance Co. Ltd. | adityabirlahealthinsurance.com |
| 2 | Care Health Insurance Ltd. | careinsurance.com |
| 3 | Galaxy Health Insurance Company Limited | galaxyhealth.com |
| 4 | Narayana Health Insurance Ltd. | narayanahealth.insurance |
| 5 | Manipal Cigna Health Insurance Co. Ltd. | manipalcigna.com |
| 6 | Niva Bupa Health Insurance Co. Ltd. | nivabupa.com |
| 7 | Star Health & Allied Insurance Co. Ltd. | starhealth.in |
+----+-------------------------------------------+-----------------------------------------------+
Operational tip (compliance): For vendor onboarding (TPA, insurer, broker, corporate agent), always validate the entity on IRDAI “registered insurers” lists before signing agreements.
Insurance operations in India are governed through:
Insurance Act, 1938 and associated rules/notifications
IRDA Act, 1999
IRDAI regulations (registration, policyholder protection, health insurance, TPAs, etc.)
To operate legally, an insurer must obtain an IRDAI Certificate of Registration. The “Registration of Indian Insurance Companies Regulations” define the application forms, documentation, and evaluation criteria (e.g., completeness of requisition, operational readiness, governance, etc.).
Typical compliance expectations include (non-exhaustive):
Incorporation as an eligible Indian company (as per regulatory requirements)
Board/management governance and “fit & proper” standards
Capital and solvency norms (as prescribed by IRDAI)
Product filing/approvals, underwriting and claims processes
Investment management and financial controls
Data retention / reporting obligations (as per applicable regulations)
Use the IRDAI regulation documents as the authoritative reference for exact forms/requirements and updated amendments.
IRDAI health insurance regulatory FAQs state that:
Insurer must settle or reject a claim within 30 days of receiving the last necessary document.
Except suspected fraud cases, insurers should not treat documents outside policy T&Cs as “necessary”.
Documents should be requested in one go, not in a piecemeal manner.
IRDAI policyholder guidance indicates:
You can port to another insurer and the new insurer shall allow credit gained for waiting periods for pre-existing conditions, as per rules.
Portability is typically requested at renewal, and IRDAI guidance commonly references request at least 45 days prior to renewal.
Cashless claims often run through a TPA (or insurer’s in-house arrangement). TPAs are regulated under IRDAI TPA regulations and provide claim servicing functions under insurer agreements.
Choose plan category based on use case:
Individual policy: one insured person
Family floater: shared sum insured across family members
Senior citizen plans: higher age bands, specific underwriting rules
Group health (employer): corporate coverage with HR/admin controls
Top-up / Super top-up: kicks in after deductible; cost-effective for higher cover
Critical illness cover: lump-sum on listed conditions (product-specific)
OPD / maternity / dental: usually optional riders or specialized plans (varies)
Most insurers evaluate:
Age of insured members
Sum insured and room rent limits/sub-limits
Pre-existing diseases (PED) and disclosure completeness
Lifestyle (tobacco/alcohol), BMI (in some cases), occupation risk
Past medical history, prior claims, existing policy details
Waiting periods, co-pay, deductibles, exclusions
Best practice: Never “optimize” answers in proposal forms. Misrepresentation is a top cause of claim disputes.
Family members, age, PED list
Target sum insured (e.g., ₹5L/₹10L/₹25L)
Hospital preference (network coverage near your city)
Riders required (maternity, OPD, critical illness, etc.)
Risk controls: co-pay acceptable? room rent cap acceptable?
Cross-check insurer name on IRDAI registered lists:
Health insurers list (Standalone)
General insurers list (Non-life)
Life insurers list (if buying rider-based cover)
Check:
Waiting periods (initial, PED, specific treatments)
Exclusions and permanent exclusions
Sub-limits (room rent, ICU, specific procedures)
Co-pay, deductible, disease-wise caps
Cashless network, TPA support, pre-auth process
Fill proposal form with accurate disclosures
Upload KYC documents (as asked)
Medical tests if required by insurer rules
Immediately after receiving policy:
Verify names, DOB, sum insured, plan variant, riders
Save policy PDF + wordings + brochure + terms
Store insurer/TPA helpline numbers
IRDAI policyholder guidance describes claim paths and emphasizes understanding the process early.
When to use: Planned or emergency hospitalization at a network hospital.
Workflow
Go to network hospital (verify network via insurer/TPA portal/app)
Provide e-card/policy details at insurance desk
Hospital sends pre-authorization request to insurer/TPA
Insurer/TPA approves/queries/partially approves as per policy
On discharge, final bill is shared; insurer settles admissible amount directly
You pay:
Non-admissible expenses
Co-pay/deductible
Consumables not covered (policy dependent)
Key control: Keep copies of admission notes, discharge summary, final bill, prescriptions.
When to use: Non-network hospital or cash paid due to emergency / non-availability.
Workflow
Pay hospital bills yourself
Collect full documentation set (see checklist below)
Submit claim form + documents to insurer/TPA as per channel
Insurer processes claim; may ask queries (should not be piecemeal except special cases)
Settlement/rejection should be within timelines as per IRDAI guidance
Claim form (filled and signed)
Policy copy/e-card
Hospital bills (itemized) + payment receipts
Discharge summary
Doctor consultation notes
Prescriptions + pharmacy bills
Diagnostic reports
ID proof / KYC (if asked)
Cancelled cheque / bank details (for reimbursement)
Cause: Proposal form mismatch vs medical records.
Fix:
Always disclose conditions and medication history
Keep proposal copy archived
If disputed, escalate with written evidence and policy terms
Cause: Many policies exclude consumables (gloves, syringes, etc.) or have caps.
Fix:
Choose plans with fewer consumable restrictions (where available)
Ask hospital to separate admissible vs non-admissible items pre-discharge
Cause: Policy room rent cap or procedure-wise limits.
Fix:
Before admission, confirm eligible room category
Upgrade sum insured/plan variant at renewal if needed
Norm: IRDAI guidance expects documents to be called at one time (except fraud suspicion).
Fix:
Ask for the “complete list of required documents” in writing
Provide everything in one submission with an index
Norm: IRDAI FAQ notes settlement/rejection within 30 days from last necessary document.
Fix:
Track “last document submission date”
Escalate to insurer grievance + IRDAI grievance mechanisms if unresolved
Health insurance workflows handle sensitive personal data:
Identity documents
Medical records and diagnoses
Bank account details
Hospital documents
Use encrypted storage for policy and claim archives (BitLocker/FileVault or encrypted cloud drive)
Share documents only through official insurer/TPA portals or verified email IDs
Mask/limit sharing of Aadhaar where legally appropriate (share only when required)
Maintain least-privilege access for HR/admin teams handling group policies
Buy early to reduce underwriting friction and waiting-period impact
Prefer adequate sum insured considering city-wise hospitalization costs
Keep policy active (avoid lapses); plan renewals and portability windows early
Save every endorsement and renewal schedule
Maintain employee census with DOB/dependent mapping
Standardize claim submission SOP + document checklist
Run quarterly audits: claim ratios, network utilization, turnaround times
Vendor onboarding must include IRDAI verification of insurer/TPA/intermediary lists
Health insurance in India is a regulated product ecosystem. The most reliable way to stay compliant and avoid claim disputes is to:
Purchase only from IRDAI-registered insurers (Standalone/General/Life categories as applicable).
Understand the cashless vs reimbursement workflows and keep documentation ready.
Track claim processing norms (including document handling and settlement timelines).
Use portability correctly at renewal windows and preserve waiting-period credit where applicable.
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