Vol. 3 No. issue 1, March, 2026, page 2143-2158 (2026): An Analysis of Legal Challenges in Health Insurance Claims in India: Examining Consumer Rights, Regulatory Protection, and Insurer Accountability

The aim of this research is to evaluate legal challenges linked to health insurance claims in India which specific focus on regulatory protection, insurance accountability and consumer rights.  The study will contribute to understanding if existing regulatory and legal mechanisms protect policyholders against delays, unfair detection, as well as partial settlement of claims.  According to IRDAI's policyholder-protection framework, policyholders are required to approach the insurer's grievance mechanism as well as offer access to IRDAI's grievance-redressal system in case of unresolved conflict. In this study, secondary data has been used. Data in the form of interviews, questionnaires, surveys and the like has not been used. The legal sources have included Indian law, IRDAI rules and circulars, Insurance Ombudsman guidelines, judicial decisions and consumer forum decisions. The interpretation of these provisions becomes contentious if policyholders believe that insurers have applied a situation which cannot be understood while purchasing the policy. Judicial decisions illustrate that insurers cannot depend only on technical interpretations where the situation highlights unreasonable claim handling, failure to comply with regulatory and contractual obligations, as well as inadequate disclosure.

Keywords:  Health insurance claims, IRDAI, policyholders, insurers, Healthcare