Filed an RTI with the Office of the Insurance Ombudsman, Delhi, asking for basic statistics on how they handle complaints, volumes, hearings, awards and timelines. Got a reply this week. Posting the numbers here since I think they're useful for anyone who has a complaint pending with an Ombudsman office or is thinking about filing one. No commentary, just the Q&A as given.

Complaints received

• FY 2024-25: 3,665
• FY 2025-26: 4,686
• No separate record is maintained of how many were filed online vs offline.

Closed without any hearing or award

• FY 2024-25: 1,007
• FY 2025-26: 627

Hearings conducted

• FY 2024-25: 3,038
• FY 2025-26: 3,068
• No data available on how many were online (video conferencing) vs in-person.

Awards passed, and who they favoured

• FY 2024-25: 644 total awards; 79 in favour of the complainant, 565 in favour of the insurer (roughly 12% complainant-favourable)
• FY 2025-26: 795 total awards; 139 in favour of the complainant, 656 in favour of the insurer (roughly 17% complainant-favourable)

Average time from filing to hearing, and hearing to award

• Refused. The reply states this "is not available hence unable to provide as per section 2(f) of the RTI Act, 2005."

Complaints closed for non-submission of documents by the complainant

• Refused under the same Section 2(f) ground: "not available."

Complaints with duplicate registration numbers for the same underlying complaint

• Refused under the same Section 2(f) ground: "not available."

Awards passed beyond the 3-month timeline prescribed under Rule 17(4) of the Insurance Ombudsman Rules, 2017

• "No data available" for either year.

Standard operating procedure for choosing online vs physical hearings

• "There is no such copy of the SOP on video conferencing available." The office says it is governed generally by the Insurance Ombudsman Rules, 2017, which don't prescribe this in detail.

Recording of hearings

• Hearings are recorded, but only as a single composite recording covering all cases heard that day, not separately per case. No separate retention guideline was given.

Who decides the hearing mode (online vs in-person)

• Scheduling is done by "the dealing official." The choice of mode is stated to be "verbally approved" by the Ombudsman, with no written policy or documented criteria.

Administrative reporting line

• The Office of the Insurance Ombudsman, Delhi is governed by the Insurance Ombudsman Rules, 2017 and reports administratively to the Council for Insurance Ombudsmen, Mumbai.

Sharing this mainly because I hadn't seen anyone post the actual award-outcome ratio before, and the volume numbers help put an individual complaint in context (thousands filed per year, out of which a large share never even reach a hearing or award).

Happy to answer questions on the RTI process itself if anyone's thinking about filing a similar one with their own state's Ombudsman office; the fee is Rs. 10, and the format is on rtionline.gov.in.

So hello guys
Iam from Kerala, I got to know about our central govt scheme of Ayushman Bharat health insurance scheme
Which covers upto 5lakh annually..
My family is of 10 memebers(according to ration card)*
I have grandmother and grandfather , both are in their 60’s..

So I would want you guys to help me out
The queries are ,

1. how to apply ? Where to apply? Are there any requirements?
2. can we apply via online?
3. is it only available for senior citizen?
4. Whats this new “vay Vandana card” ? Should I apply for that first before going with ayushman card?
5. Since I belong to Kerala - karntaka border place , I don’t have much hospitals near to me , we have to depend on Karnataka for that, so will Ayushman card registered in Kerala be useful for Karnataka hospitals?

Help me out guys
Thank you

Hey everyone,

I’m 29, looking to buy a comprehensive retail floater policy for my spouse and me. We have a completely clean slate with no pre-existing diseases (PEDs) or past medical history.

Since I already have a corporate cover to handle minor hospitalizations, this retail policy is strictly meant to be a 30-year backup for catastrophic, high-cost events (cancer, advanced surgeries, etc.).

I was heavily leaning towards Niva Bupa ReAssure 3.0 (Black) because of the unlimited base cover and lower premium. However, I read the actual policy wording and found a major red flag under Page 44, Section 7.A (Position Statements & Medical Protocols).

1. The Procedure Downgrade Clause

> "If in any treatment our position, based on scientific evaluation, is not to pay or pay only a part, we will at least pay up to the cost of currently prevailing most common alternative treatments for the condition and not less."

* My Interpretation: If my doctor recommends an ₹8 Lakh robotic surgery, Niva Bupa has the explicit contractual right to downgrade the payout to a ₹3 Lakh open surgery (the "common alternative"), leaving me to pay the ₹5 Lakh difference out of pocket.

2. The Oncology / Off-Label Ban

> "Extra / Off label usage (using a drug or procedure for conditions other than it was explicitly approved for) will not be covered under the policy."

* My Interpretation: Modern cancer treatments heavily rely on oncologists prescribing approved targeted therapies "off-label" for different tumor mutations. Under this clause, Niva Bupa can legally reject a ₹20 Lakh life-saving drug entirely.

My agent insists I’m overthinking it and says, "If the doctor writes it's medically necessary, they have to pay." But standard contracts like HDFC ERGO Optima Secure+ rely purely on medical necessity without these specific downgrade clauses (though their premium is much higher).

Questions for claims experts / actuaries / ReAssure 3.0 policyholders:

* Has anyone actually had an advanced surgery downgraded or a cancer drug rejected by Niva Bupa specifically citing Section 7.A?

* Is this just harmless industry boilerplate, or is it the actual legal mechanism they use to control their "unlimited" claims pool? Because even ombudsman will rule in their favor as they specifically have this clause in their contract that i agreed to when buying policy.

* Since we have no PEDs and a clean medical history, shouldd I just swallow the higher premium for HDFC ERGO to lock in a completely clean contract?

*I also suspect portability as a mayor issue to move out of Niva Bupa due to unlimited sum insured.

TL;DR: Niva Bupa ReAssure 3.0 has a hidden clause (Section 7.A) giving them the legal right to downgrade advanced surgery payouts and completely reject off-label cancer drugs. HDFC ERGO doesn't have this but costs significantly more. Trying to figure out if this clause is a dealbreaker for major medical crises for a young, healthy couple.

Honestly lose for words at how broken this entire platform is. I’ve been trying to change my monthly premium payment method for DAYS now and the website is completely useless.

To make matters worse, support is an absolute joke. Every time, some brainless bot sends me the exact same broken link that doesn't work. There's no way to reach a customer care agent. How hard is it to give basic instructions or just fix a payment portal?

I’m paying for a service and I literally can’t even give you my updated card because your system and customer service are both complete trash. Anyone else dealing with this or know a way to actually get through this?

Why no capping is suggested? If I am fine taking shared room and it brings my premium down, how it can hurt me in future? Do hospitals handle such patients differently? I am about to buy my first policy and looking for some advice.

Hi All

My parents are 65+ . I got a 5 lac comprehensive Star Health policy for parents 10 years ago. My parents have diabetes, prostate (dad), high blood pressure. We havnt claimed the policy yet so it has accumulating bonus as cover is around 10 lacs. I realize now that 5 lac is not enough. Hence trying to understand what options are available. I am trying to target a coverage of around 20-25 lacs.

1. Option 1: Ask Star Health for increasing the Sum Insured during next renewal before my dad turns 70. I understand they have the option to say no.
2. Option 2: Take top up policies. The only 2 I can find is Manipal Cigna and Care Enhance Supreme. Both are offering ~20 lac SI with 5 lac deductible for around 30K. However this will have the 3 year wait period for existing diseases.For both I cant find if there is a co-pay since my parents are above 60 yrs of age

Does anyone have recommendations of the way to proceed. Would really appreciate some guidance here

In January 2026, I decided to buy term insurance through PolicyBazaar.
During the sales pitch, the agent recommended an ICICI Prudential plan. I declared myself as a smoker on the application. However, the agent explicitly assured me over the call that this policy allows for a lifestyle change update after 1 year of quitting smoking, which would significantly reduce my future annual premiums.
Having successfully quit smoking recently, I reached out to check the process. Turns out:
The policy requires at least 3 consecutive smoke-free years (not 1 year) to even be considered a non-smoker.
More importantly, the insurer confirmed that the premium amount is locked in for the policy term and will not decrease.
I know I should have thoroughly read every clause in the policy document instead of taking the agent's word for it, but I fell for the sweet talk and made the purchase based on that promise.
Given the situation:

1. What are my realistic options right now? (Since it has been several months, the 15/30-day free-look period has passed).
2. Is it worth porting/reapplying for a fresh non-smoker policy once I hit the required smoke-free milestone, or will the entry age increase cancel out any savings?
3. How can I escalate this and take formal action against the PolicyBazaar agent for mis-selling? Can I request call recordings through an IRDAI / Bima Bharosa grievance?
   Any advice from people who have handled mis-selling complaints or navigated term plan re-evaluations would be really appreciated.

Ps: used Gemini for readability

I had looked into the options beforehand but their agents wouldn’t assist with certain plans offered by the same company. Even among the plans they recommended, they wouldn’t allow me to add some of the riders I wanted. Also, when considering coverage for multiple family members, they recommended a family floater rather than multi individual thing mainly because it would reduce the overall premium. I’m wondering whether these recommendations are genuinely based on what they consider best for the customer or whether they are influenced by their own restrictions or the plans they are authorized to sell.

Hi everyone,

​We have finalized a family floater health insurance policy with HDFC ERGO (paid as a single annual upfront payment):

• ​Self (50M), Wife (48F) (mild BP, adding ABCD rider), 2 Sons (18M, 13M)
• ​Base Cover: ₹15 Lakhs with ₹25,000 Aggregate Deductible

​The upfront premium difference between Optima Secure and Optima Secure Plus (Secure+) is only ~₹1,000, but our agent is strongly pushing us away from Secure+.

​Key Questions:

1. ​Renewal Pricing on Secure Plus: The agent claims that because Secure+ adds a 100% bonus every year (Infinite Benefit), HDFC will re-price future renewal premiums based on the higher compounded cover (e.g., pricing it like a ₹30L base next year), leading to huge renewal spikes. Is this true, or is the renewal premium for both plans calculated strictly on the original ₹15L base rate?
2. ​Which One to Pick?
   • ​Optima Secure: Caps bonus at 2X (max ₹30L in 2 years) + 1 restoration/yr.
   • ​Optima Secure Plus: +100% (+₹15L) added every year without an upper cap + unlimited restorations. With just a ~₹1,000 upfront price difference, does Secure+ make more sense for long-term medical inflation, or does it become disproportionately expensive on renewals?
3. ​Expected Renewal Hikes: What kind of year-on-year % increase should we expect over the next 5–6 years as the eldest member crosses into the 51–55 age bracket?

​Lastly, I am concerned because the agent explicitly warned: "Do not buy Secure Plus because you will not be able to afford it after some time compared to Secure." Is his warning justified or misleading?

​Would appreciate guidance from HDFC ERGO policyholders and insurance experts!

Note: Used AI to help structure and clearly articulate my thoughts here, but all details and questions are 100% genuine

My brother is 22M, currently unemployed, and doesn't have health insurance. He wants to undergo LASIK for both eyes, and the hospital has quoted around ₹1.5 lakh.

We are planning the surgery 7–8 months from now, so we are considering buying health insurance now and using it for the surgery later.

Could you please suggest good health insurance policies in India that cover LASIK, preferably with a waiting period of less than 7–8 months?

Also:

Is LASIK actually covered under these policies?

Are there any conditions, such as a minimum eye power/dioptre requirement?

What percentage/amount can realistically be reimbursed?

Has anyone here successfully claimed LASIK through health insurance?

We don't want to buy a policy and later discover that LASIK is excluded. Any recommendations based on actual experience would be very helpful.

My parents are currently covered under a Star Health medical insurance policy, but we have experienced significant delays and difficulties with both cashless pre-authorizations and post-treatment reimbursement claims. Consequently, I am looking to port their coverage to a more reliable insurer.

In my preliminary research across providers like Tata AIG, ICICI Lombard, ManipalCigna, Niva Bupa, and HDFC ERGO, I noticed that entry age limitations restrict coverage options for individuals over 75, with ICICI Lombard and HDFC ERGO appearing to be the primary options. I would appreciate your guidance on the most suitable policy and provider for senior citizens given these constraints.

My uncle has star health insurance and paying all timely premiums since last 10 years. Yesterday my uncle slipped at home and fractured his Femur bone. I went to show my uncle at Star Health panel hospital where cashless treatment is allowed. Doctor did a regular blood test and x-ray and then forwarded case to PAC (Pre-Anesthetic Checkup) before Surgery to fix the bone . In PAC, all the basic details were noted by doctor before a surgery. Then hospital submitted case for cashless treatment approval to star health after submitting an estimate and other documents.

Star health with 20 minutes rejected the claim by picking a point from PAC where all the basic details mentioned such as no medications, allergy, lifestyle and 'socially consume alcohol' and quoted following:

"Based on the submitted medical records, it has been observed that the insured patient has undergone treatment for a condition resulting from the use of alcohol, drugs, or substance abuse. As per Alcoholism, drug or substance abuse Exclusion Code 12, the policy excludes coverage for any expenses incurred for treatment related to alcoholism, drug or substance abuse, or any addictive condition and its consequences. Therefore, we regret to inform you that the claim is not admissible."

There was nothing to substantiate to this reason in the documentary form such as in the blood test or anything. Now what to do because it is very illogical because the cause of fall is nowhere written as under influence of alcohol. We went ahead for surgery by bearing all the cost from the pocket. Please advise what should i do?

Edit: i have 2 choices either i get remark from PAC doctor that he wrote down 'social' in alcohol column due to mis communication and state there is no alcohol history.

Or i get remark from ortho doctor who did surgery that there is no alcohol sign in patient and in his blood reports which may relate to this injury. (This time we may get claim but in future, there are chances if we go for any heart, liver ir other related issue, They will outrightly deny the claim stating this 'social' remark in PAC report.

Please guide with which option i should go?

https://preview.redd.it/wc2uhmxfi2kh1.png?width=996&format=png&auto=webp&s=7a46da560ad9deeb94beaf0ea77a79567186e4b7

An unmarried female friend needs an abortion, and the hospital requires an ABHA ID. She is worried the record could later become accessible to family members, insurers, etc.

Would this technically work?
ABHA 1 → abortion record gets linked → permanently delete ABHA 1 → create a new ABHA 2 later for normal/future healthcare.

Would ABHA 2 be completely separate from ABHA 1 and its records, or can the old records/linkages still be connected to her?

Hello, quite a few times I asked about this query. May be not in a proper way.

Last year I applied for individual policy for myself.32f, through ditto for hdfc. I trusted them both to be best. But don't know were the mistake happened.

My application got rejected.stating adverse medical reasons. On the advise i disclosed every small thing n in form even though I was not diagnosed with anything in form I filled symptoms which looked severe. After rejecting i relaised it's stays in insurance database.

. The worst as it's officially rejected it's stays in database.

My issue was not rejection. They have right to reject.but the rejection mail has used symptoms as disorders that wil become difficult to reapply.also they stated I have hypertension which was on one opd paper.

After all these I read about insuarnce , I had already given up .but I think I shud give one more try.

Some agents said not to disclose about it in other application ( which i am not okay with)

I even got medically fit certificate from phyisician.

Eventually it stressed me out for a year .

What can I do to resolve ?

Should I go for grieveiance ?

Should I ask Ditto again to help

Or ask Hdfc?

Will it be ok to do so ?

I had also asked suggestion from people on reddit ?

Something just dint convince me or give me peace of mind.

What exactly can help me?

I want a policy for myslef so I get peace of mind n focus on other things .

Notes - i shared my opd papers ,.they dint call.or ask or explain anything. Always got an automated reply from hdfc when asked about rejection clarification.

#trying once again #honestsuggestions.

Getting helath insurance is an adventure :) Be kind :)

I bought HDFC ERGO Optima Secure+ from Policybazaar for ₹31,043 and selected 18 months No Cost EMI.

After the EMI was converted, I checked the HDFC details and saw that interest is being charged. Total interest is around ₹2,966.

I contacted Policybazaar regarding this and after some back and forth, they replied that the interest amount will be given back as cashback by the bank within 60–90 working days.

Has anyone here faced the same thing with Policybazaar?

Did you actually get the cashback? And is there anything I should ask them or confirm before I just wait for 60–90 days?

Would be helpful if someone who has gone through this can tell me what they did.

I have an HDFC Ergo Optima Secure policy, which I've had for 4 years. The base sum assured is 50 lakhs (25 for me + another 25 for my wife when I added her last year; there are two individual covers under the same policy, not a family floater). Neither of us has any PEDs, and we've never had to make a policy claim.

I would like to know if converting to a family floater has any advantages or if I should keep it as an individual policy.

With medical inflation on the rise and the fact that Optima Secure does not offer any NCB after two years when the sum assured basically triples, should I consider doubling the base sum assured during the next renewal instead of waiting a few years?

I bought this policy directly from the website. I had to make an update to the policy this year, and HDFC Ergo customer care was a nightmare. I had to escalate to the CGO for a minor update. Should I consider porting out next year and buying a policy through an intermediary this time? I am afraid that I will face the same troubles with customer care during any future claims.

Hi everyone,

I’m looking for some genuine advice on health insurance for my parents. I’m trying to make a long-term decision now rather than waiting until they are older or develop more health issues.

Parents
Dad: 54 years old
Mom: 49 years old

Current health
Mom: Some leg pain and dental issues, but no other major health problems.
Dad: Cholesterol levels fluctuate / has cholesterol issues, but otherwise no major health problems.
No major surgeries or hospitalisations that I’m aware of.

Current insurance
We currently have an Oriental Insurance health policy.
From the policy document I have:
Dad: ₹5 lakh sum insured + ₹2.1 lakh cumulative bonus
Mom: ₹2.5 lakh sum insured + ₹87,500 cumulative bonus
Premium: around ₹26,000/year
The policy is already active and has some continuity/accumulated bonus.
My main concern is that the coverage may not be sufficient as they get older.

What I’m confused about
Should I:
A) Continue the existing Oriental policy and add a super top-up?

B) Continue Oriental but try to increase the existing coverage?

C) Keep Oriental for now and buy separate individual policies from another insurer such as HDFC ERGO or another reputed insurer?

D) Cancel/switch from Oriental completely and move to HDFC ERGO or another insurer?

I’m particularly interested in understanding whether cancelling an existing policy with accumulated continuity/bonus is a bad idea, especially when the parents already have some existing health conditions.
How should I actually compare policies?

Apart from premium and sum insured, what should I look at?
For example:
Room rent limits
ICU limits
Co-pay
Disease-specific sub-limits
PED waiting period
Claim settlement experience
Cashless hospital network
Restoration/recharge benefits
No-claim/cumulative bonus
Lifetime renewability
Any hidden exclusions
Whether a super top-up makes sense

Ditto vs local insurance agent
I’m also confused about where to purchase it.
Is Ditto a good option for researching/buying health insurance? Is their advice genuinely useful, or is it better to speak to a good local insurance agent/broker who can help during claims?

For parents’ health insurance, does the intermediary actually make a meaningful difference during a claim, or is it mostly about choosing the right policy directly from the insurer?

I’m not looking for the cheapest policy. I want something that will be reliable for the next 15–20 years, especially when my parents are older and more likely to need it.
If you have actually bought health insurance for your parents or have gone through a claim, I’d really appreciate your experience.

Would you personally continue the Oriental policy in this situation, add a super top-up, or switch to HDFC ERGO/another insurer? And how would you make that decision?

Used AI for better writing !

Hi everyone,

I am looking for urgent advice on a health insurance policy for my sister. She is 25 years old.We have recently majored in a roadblock regarding her treatment cost.

Medical history and context :

Initial diagnosis: in 2021 mctd with sle.

Progression: in june 2026 she has major critical condition pulmonary arterial hypertension, ild, lupus nephritis, hyperbilirubanic anemia.

Current diagnosis: she is in long term medication and long period of hospitalization.

Financial problem/ insurance problem:

Insurance problem:Every insurance has a waiting period for ped.

Treatment: she needs to cover medicine and hospitalization charges.

What I am looking for:

Low waiting period: are there any specific policies which have a low waiting period? May be 30 days or immediately?

My questions:

How can I proceed with this kind of condition?

I never had any kind of insurance in my family.

What should I specifically look for in insurance?

Should I take critical care insurance?

Which company provides the best insurance in india?

Has anyone with long term condition like this successfully used ped reduction for immediate claim for auto immune disease?

Any leads on specific plans, who handle this kind of condition that would be huge help. Thank you in advance.