Another old turf war is bubbling over once again in the healthcare space, this time between the clinical community and healthcare insurance players. The General Insurance Council (GIC)’s advisory on Admission Criteria for Fever and Infectious Diseases has been a red flag, with clinicians seeing it as an encroachment on their clinical decision making process.
The context to this latest flareup is last year’s agitations by health insurance providers moving certain hospital chains from their coverage. Healthcare providers had retaliated by withdrawing cashless facilities for certain health insurance companies. As usual, patients were caught in the middle of this tit for tat.
Since then, there have been attempts to build a consensus and resolve these issues. Meetings convened by the General Insurance Council, which represents more than 30 insurance companies, with key hospital associations, have tried to find common ground. These trust building overtures, steered by the newly formed Health vertical at GI Council and headed by Dr S Prakash, CEO, General Insurance Council (Health Insurance Ecosystem and Strategic Partnerships) resulted in the release of a GIC Advisory on Admission Criteria for fever and infectious diseases (2024-25) based on these consultations.
But hospitals have pushed back once again. Hospital associations like The Association of Healthcare Providers India have rejected the advisory, claiming that even though it is couched as an advisory, it might be used by insurance providers to reject legitimate medical claims. They point out that insurance companies have a vested financial interest and therefore should have no sway over any part of the clinical decision making process.
In a statement clarifying its stance, the GI Council addressed the misconception that referencing clinical guidelines constrains medical autonomy. The statement points out that as India’s health insurance sector has expanded rapidly, so has misuse. Between 2019 and 2024, unnecessary hospital admissions (as deemed by GIC) have surged dramatically. GIC’s data shows that Rs 94,247.6 crore in total health claims settled in 2024-25, with cashless-only admissions accounting for 66.4 per cent of the volume.
The Council’s perspective is that the insurance industry receives hundreds of claims monthly that appear to misuse the privilege of coverage, including admissions for trivial fever, unnecessary investigations, and extended stays that do not align with clinical evidence or international best practices.
As per the statement, the advisory was developed to address this crisis-not to restrict legitimate clinical practice, but to combat systematic abuse that inflates premiums for the common man and diverts resources from genuine patient needs.
The GIC advisory is reportedly “derived from and references the clinical guidelines established by The Indian Council of Medical Research (ICMR), The Ministry of Health and Family Welfare (MOHFW) and The National Vector Control Board, and “simply operationalises these government-mandated clinical standards within the health insurance ecosystem.”
The GIC press statement also references similar systems globally, pointing out that in the UK, National Institute for Health and Care Excellence (NICE) sets clinical guidelines; NHS coverage follows these standards.In the US, CMS references guidelines from NIH, specialty societies, and state health departments. In Australia, Canada, Germany too, all insurers reference government and statutory health authority guidelines. Is India’s healthcare sector evolved enough to be benchmarked to such systems?
The GIC statement stresses that the advisory is not a rule book, and it does not restrict clinical autonomy. It is a framework for appropriate, evidence-based practice. The statement avers that true clinical autonomy is the right to deviate from guidelines when clinically justified-provided that deviation is documented, reasoned, and open to review.
At the heart of this tug of war is a system to balance the clinician’s judgement of care and insurance’s mandate to keep premiums and payouts credible and sustainable.
Thus the face off continues, with hospital groups reportedly pressing for an Insurance Redressal Forum to resolve such policy disputes more effectively. Until then, patients will be left to wonder if a hospital is advising too early admissions or if their health insurance will suddenly cease to exist. Policy makers need to step in to address these issues and rebuild trust in the healthcare ecosystem.
VIVEKA ROYCHOWDHURY,
Editor
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