The clarification follows concerns raised by sections of the medical fraternity over GIC’s 2024-25 advisory on admission criteria for fever and infectious diseases.
S Prakash, CEO, Health Insurance Ecosystem and Strategic Partnerships, General Insurance Council, said the advisory is based on clinical guidelines issued by public health institutions, including the Indian Council of Medical Research (ICMR), the Ministry of Health and Family Welfare (MoHFW), and the National Vector Control Board.
“The advisory is not an independent prescription by GIC but references existing government health guidelines and seeks to operationalise them within the health insurance ecosystem,” the council said.
Why did GIC issue the advisory?
According to GIC, the advisory was introduced against the backdrop of concerns around unnecessary admissions, avoidable investigations and extended hospital stays that can increase healthcare costs.
The council said health claims settled by the insurance industry stood at ₹94,247.6 crore in 2024-25, with cashless-only admissions accounting for 66.4% of claim volumes.
GIC said admissions that do not align with clinical requirements can contribute to higher costs for policyholders and impact the affordability and sustainability of health insurance.
Does the advisory restrict doctors’ decisions?
GIC said the advisory is not a rule book and does not override a doctor’s clinical judgment.
The council said doctors retain the authority to admit patients based on medical circumstances. If a doctor chooses to deviate from the framework in a particular case, the decision can be supported with clinical reasoning and documentation, it added.
According to GIC, the purpose of the framework is to encourage appropriate use of healthcare resources while ensuring that patients receive treatment based on clinical evidence.
How does it affect patients?
GIC said the framework is aimed at ensuring that patients receive hospital care when medically required while avoiding unnecessary hospital stays.
The council said unnecessary admissions can expose patients to additional risks, including hospital-acquired infections, medication-related issues and higher out-of-pocket expenses. It also said avoidable hospitalisations can contribute to higher premiums for policyholders.
Will the guidelines remain fixed?
GIC said the advisory is a “living framework” and can evolve based on changes in clinical guidelines and feedback from medical experts, hospital associations and professional bodies.
The council said it would continue discussions with stakeholders to develop a health insurance ecosystem that balances patient protection, affordability of coverage and evidence-based medical practices.
