Lucknow: Health insurance coverage among households in Lucknow has more than doubled from about 16% in the National Family Health Survey (NFHS)-5 to 34% in NFHS-6 (2023-24), but policyholders continue to report delayed reimbursements, claim rejections and partial settlements, pointing to a persistent gap between enrolment and access to benefits.Gomtinagar resident Arjun Agarwal said he has been waiting for four months for the settlement of his 84-year-old father’s claim after a stroke and a 10-day hospitalisation at a private facility. Agarwal said his father had a Rs 10 lakh policy with cashless coverage, but an insurer representative advised him to pay hospital expenses upfront and seek reimbursement later.He alleged the insurer then raised repeated queries, requiring multiple visits to the hospital to collect documents and clarifications. Despite follow-ups, the claim remains unsettled, he said.“I paid the hospital expenses after being assured of reimbursement. For four months, I have been making repeated trips to the hospital over insurer queries. I want the claim processed and a clear timeline for payment,” Agarwal said.Similar complaints have surfaced from other insured residents. Experts estimate that at least 7% of claims are rejected, while in about 70% of cases the settled amount is reduced for various reasons, adding to out-of-pocket burden even for families with active policies.Indiranagar resident Angad Singh (54) said his Rs 1 lakh claim was rejected after he was hospitalised following a COPD attack. Singh alleged the insurer cited the absence of the original X-ray film even though the hospital provided a radiology report. “I have sought an explanation for the rejection and reconsideration of the claim,” he said.In another case, the family of Riya Singh (28) from Balaganj said the insurer approved only Rs 20,000 against total treatment expenses of Rs 80,000 after her hospitalisation during pregnancy. Her husband, Sumit Singh, said the insurer informed them that Rs 20,000 was the maximum payable for the condition. “We were not told at the time of buying the policy that pregnancy costs were capped at Rs 30,000, and even that amount was not given,” he said.Insurance professional Rama Shankar Lal, with around 25 years of experience, said claim outcomes are often shaped by waiting periods, sub-limits and documentation requirements. He said insurers may seek records of prior consultations and diagnostic reports, while treatment at non-network hospitals can trigger additional paperwork and reimbursement delays. Lal advised policyholders to preserve medical records, itemised bills and payment receipts.Advocate Narendra Kashyap, practising at Lucknow Bench of Allahabad high court, said policyholders should seek written reasons for rejections, delays and deductions and keep a record of communications with insurers. If grievances remain unresolved, he said, policyholders can approach the insurer’s internal grievance redressal mechanism or move the consumer commission depending on the dispute.
