Between 2019 and 2024, unnecessary hospital admissions have surged dramatically. Data shows 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 insurance industry receives hundreds of claims monthly that appear to misuse the privilege of coverage—admissions for trivial fever, unnecessary investigations, and extended stays that do not align with clinical evidence or international best practices,Dr S. Prakash, CEO,Health Insurance Ecosystem and Strategic Partnerships, General Insurance Council.
Mumbai:The General Insurance Council, the official representaive body of domestic general insurers, has clarified that it recognises the concerns raised by certain sections of the medical fraternity regarding its advisory on admission criteria for fever and infectious diseases in 2024–25.
“We welcome this debate. However, we must clarify the intent, foundation, and design of this advisory—and address the misconception that referencing clinical guidelines constrains medical autonomy.This advisory is fundamentally about protecting the common Indian.
,” said Dr S. Prakash, CEO,Health Insurance Ecosystem and Strategic Partnerships, General Insurance Council, in a statement on Monday.
“India’s health insurance sector has expanded rapidly—and so has misuse. Between 2019 and 2024, unnecessary hospital admissions have surged dramatically.Our data shows Rs 94,247.6 crore in total health claims settled (2024–25), with cashless-only admissions accounting for 66.4 per cent of the volume,” added Prakash.
This is not a marginal problem. The insurance industry receives hundreds of claims monthly that appear to misuse the privilege of coverage—admissions for trivial fever, unnecessary investigations, and extended stays that do not align with clinical evidence or international best practices, stressed Dr Praksh.
GI Council’s advisory was developed precisely 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,” added Praksh.
This advisory is derived from and references the clinical guidelines established by:
-The Indian Council of Medical Research (ICMR), The Ministry of Health and Family Welfare (MOHFW),The National Vector Control Board, which function under the Ministry of Health and Family Welfare and represent India’s leading public health authorities.
GIC’s advisory simply operationalises these government-mandated clinical standards within the health insurance ecosystem.By referencing established ICMR and MOHFW guidelines, GI Council ensures that:
-Patients receive evidence-based, appropriate care as defined by India’s leading public health authorities,
-Doctors practice within frameworks already endorsed by ICMR and MOHFW,
-Insurance coverage reinforces—rather than deviates from—government health policy.
“GI Council’s advisory brings the insurance sector into alignment with these frameworks—we are not creating new standards, we are operationalising established ones” stated Dr Praksh.
This advisory does not tell the technician how to do his job. It ensures the patient receives the right treatment only in the indicated situation—so they do not run from pillar to post for a second opinion, and do not spend unnecessary money when it is not clinically required, he clarified.
Hospitals resisting this model without offering evidence-based alternatives are, frankly, defending the privilege to admit without justification—not defending clinical medicine,argued Dr Prakash
Unnecessary admissions do not benefit patients. They expose them to nosocomial infections, medication errors, delayed recovery, and unnecessary out-of-pocket expenses. They inflate insurance premiums for millions of ordinary workers and families who rely on health insurance for protection. They waste government resources allocated to public health. They prevent genuine cases from accessing timely care, said Dr Praksh.
However, this advisory is not a rule book. It does not restrict clinical autonomy. It is a framework for appropriate, evidence-based practice.
Clinical autonomy remains paramount. In critical situations and emergencies, the treating doctor retains full authority to manage the patient according to clinical context and best judgment. The advisory creates no barrier to this, said the GI Council.