Should You Choose a Health Insurer Based on Claim Complaints? What IRDAI Data Actually Tells You

Every health insurer publishes claim complaint data as part of IRDAI’s mandated public disclosures. Most analyses around this data make a bold promise: a simple bar chart showing which health insurers handle claims smoothly. Fewer complaint bars = better insurer, right?

Not quite.

The metric itself, complaints per 10,000 claims registered, is real, important, and published by IRDAI for good reason. But it’s also misunderstood, misused, and frequently weaponised in marketing. This article will walk you through what this data actually means, what it doesn’t, and how much weight you should give it when choosing a health insurer.

What Is a Claim Complaint in Health Insurance?

First, the basics. A claim complaint is not the same as a denied claim or a claim under review.

According to IRDAI’s definitions, a complaint is a formal expression of dissatisfaction filed by a policyholder with the regulator or the insurer regarding claim handling. It covers things like:

• Delays in claim settlement beyond the promised timeframe
• Claim rejection without clear communication of reasons
• Request for excessive or unnecessary documentation
• Disputes over claim amounts or partial settlements
• Poor grievance redressal response
• Lack of transparency in the claim process

A complaint is something the policyholder escalated. It’s not just “my claim was denied” or “my claim took longer than I expected.” It’s a formal complaint filed by the policyholder because something went wrong.

Understanding the difference between the two is important. An insurer might deny 40% of claims in a category (which is not measured by this metric) and yet report very few complaints, because most customers didn’t escalate the denial formally. Conversely, an insurer might approve 95% of claims but have high complaint numbers if customers feel the process was opaque or terribly slow.

Bottom line: Complaint data measures dissatisfaction and escalation, not claim settlement performance or policy inclusiveness.

Why Report per 10,000 Claims?

Here’s where normalisation comes in. If IRDAI just reported raw complaint numbers, the metric would be useless. A large insurer with 5 million claims might have 500 complaints. A smaller insurer with 50,000 claims might have just 10. Which has better claims handling?

By calculating complaints per 10,000 claims, IRDAI levels the playing field. It says: “For every 10,000 claims you process, how many lead to formal complaints?”

In FY 2025-26 data:

• IFFCO-Tokio had 63.88 complaints per 10,000 claims (highest among general health insurers)
• SBI General had 4.17 complaints per 10,000 claims (lowest)

This normalisation is mathematically sound and necessary. But it also creates a false sense of precision. A 60-point difference sounds massive. And it is material, but the story behind that number is messier than the bar chart suggests.

Claim Complaints in FY 2025-26 

Health insurance claim complaints per 10,000 registered claims for FY 2025–26. Based on IRDAI public disclosures, this comparison highlights complaint ratios across General Insurers and Standalone Health Insurers (SAHIs) to help consumers evaluate insurers beyond claim settlement percentages.

Here’s the data

Visible Patterns Across Health Insurers

Looking at the infographic, a few patterns emerge:

The red zone (50+ complaints per 10,000):

• IFFCO-Tokio (63.88), Raheja QBE (53.14), Chola MS (51.84), Star Health (54.02), Care Health (42)
• These are mid-to-large players. Size alone doesn’t explain the high numbers, but market position and customer base mix might.

The orange zone (20-30 complaints per 10,000):

• Shriram, Zuno, Magma, Digit, ICICI Lombard, Niva Bupa
• This cluster includes both newer players and established ones. No clear pattern.

The yellow zone (10-20 complaints per 10,000):

• Liberty, Future Generali, ACKO, Tata AIG, Aditya Birla
• Moderate complaint levels. Still a healthy spread across company sizes and business models.

The green zone (less than 10 per 10,000):

• Bajaj General, HDFC ERGO, Universal Sompo, Indusind, SBI General
• The lowest complaint insurers. Some are large (Bajaj), some are niche.

Can you draw a conclusion? Not a single, simple one. 

• Complaint volume doesn’t correlate strongly with company size.
• Both public and private insurers appear across the spectrum.
• Both established and newer insurers appear in low-complaint and high-complaint groups.

What this suggests: Complaint volume is driven by company-specific operational choices, policy design, and claims adjudication philosophy—not by size, age, or ownership type.

Why High Complaints Are Concerning (But Not Disqualifying)

Let’s say an insurer lands in the “red zone” with 50+ complaints per 10,000 claims. Should you instantly reject them?

Not necessarily, but it’s a warning signal that needs investigation.

High complaint volume suggests:

• The insurer’s claims processes are creating friction points for customers
• Communication during claim settlement could be clearer
• There may be gaps between policy wording and customer expectations
• The insurer might be particularly strict in claim scrutiny

Any of these could affect your experience. If you file a claim, would you rather deal with an insurer known for smooth handoffs or one with a reputation for documentation requests and delays?

Now flip it. If an insurer has 5 complaints per 10,000 claims, does that mean their policies are perfect and claims are always approved?

No. And this is where the metric can be genuinely misleading.

Low complaint volume can mean:

• Claims are genuinely processed smoothly (the best case)
• The insurer’s policies are so narrow that very few customers actually file claims (customers with narrow policies are less likely to hit edge cases and dispute them)
• Customers are less aware they can file complaints with IRDAI (less transparent company culture around grievance escalation)
• The insurer settles complaints informally, reducing formal IRDAI filings

Some of these are good. Some are not.

Insurer A: 10 complaints per 10,000 claims. But their policies cover only in-hospital treatment, exclude pre-existing conditions for 4 years, and don’t include OPD. Customers aren’t complaining because they’re not filing many claims in the first place.

Insurer B: 25 complaints per 10,000 claims. But their policies are broader, include OPD, have reasonable waiting periods, and approve 85% of claims filed. More claims = more disputes = more complaints, but also more actual coverage utility.

Which would you choose? The metric alone can’t answer that.

The broader point: A low complaint number is consistent with good claims service, but it’s not proof of it. You need to cross-reference with claim settlement ratio, policy coverage, and customer reviews on claim payout experiences.

What This Metric Does NOT Tell You

Complaints per 10,000 claims is useful, but it has hard boundaries.

• It is not a measure of claim settlement ratio. 
• It doesn’t measure claim settlement speed. 
• It doesn’t measure policy quality or breadth. 
• It doesn’t measure customer service quality. 
• It doesn’t account for customer demographics. 

How This Metric Compares to Other Indicators

Claim complaints are one lens. Not the only lens.

A complete picture includes:

Claim Settlement Ratio (from IRDAI disclosures, NL-37)

This is the percentage of claims actually settled. High settlement rates paired with low complaints is solid. High complaints with high settlement ratio reflects possible service friction. Low claim settlement ratio with low complaints might indicate restrictive policies.

Premium vs. Benefit Analysis

Some insurers charge lower premiums by offering narrower policies. They might have low complaints because claims are rare. But is that a better deal than a higher premium with broader cover?

Customer Retention Rates

If customers don’t renew, it suggests dissatisfaction that might not be captured in formal complaints.

Policy Inclusions and Exclusions

Complaints don’t tell you if pre-existing conditions are covered, if no-claim bonuses apply, or if domiciliary treatment is included. These policy features often matter as much as complaint metrics.

Regulatory Action and Penalties

IRDAI publishes action against insurers for poor conduct. This is different from complaints and might indicate systemic issues not captured in complaint volume.

How to Actually Use This Metric When Choosing an Insurer

Here’s the practical advice:

Step 1: Use complaint data as a screening filter, not the final decision. At Algates Insurance, complaint volume is one of the screening metrics in our insurer evaluation framework. We generally prefer insurers reporting 20 or fewer claim complaints per 10,000 claims, but never recommend or reject an insurer based on this metric alone. We always evaluate it alongside claim settlement performance, policy coverage, waiting periods, exclusions and premium value before making a recommendation. If an insurer reports 60+ complaints per 10,000 claims, it’s worth investigating why before buying.

Step 2: Cross-reference with claim settlement ratio. Go to IRDAI’s NL-37 disclosure and find the same insurer’s claim settlement ratio, or check our own comparison of which health insurers settle claims fastest.. If they have high complaints and low claim settlement ratio, that’s a red flag. High complaints with high approval rates suggest process friction, not policy restrictions. Choose which you can tolerate.

Step 3: Check what you’re actually buying. Complaints per 10,000 claims tells you about current customers’ experiences. But if you’re buying a policy with specific riders or coverage areas, you might not face the same friction points as the average customer. Narrow policies often have low complaints because few claims are filed.

Step 4: Read customer reviews on claim experiences, not just ratings. Online reviews are unreliable in aggregate (people are angrier than happy), but they reveal why complaints happen. Customer stories beat statistics for understanding what you’ll actually face.

Step 5: Talk to an advisor with recent claim data. Complaint data is from FY 2025-26. If you’re buying in FY 2026-27, things might have changed. Good advisors often know which companies have tightened or loosened claims processes recently.

Here is a detailed guide on how to choose the right health insurer.

Algates Insurance Verdict

Claim complaint volume is a real data point worth considering. But it should not be your sole decision criterion.

Here’s why:

1. It measures process friction, not policy quality. Low complaints might mean narrow policies, not good claims service.
2. It’s backward-looking. It reflects what happened last year, not necessarily what you’ll experience. Insurers change claims teams, processes, and policies frequently.
3. It’s incomplete without claim settlement ratios. An insurer with 20 complaints per 10,000 claims but 90% approval rates is different from one with 20 complaints and 60% approval rates. You need both numbers.
4. It doesn’t reflect your specific situation. Aggregate complaint data hides variation by claim type, geography, and policy. Your experience might be better or worse than average.
5. Other factors matter more for most buyers. Premium, policy coverage, network quality, and brand stability often affect your real-world experience more than complaint volume.

When to prioritise this metric:

• You’re extremely risk-averse and want the smoothest possible claims journey.
• You’re buying a policy you expect to claim under soon (complex claim type).
• You’re comparing two insurers that are otherwise similar in premium and coverage.

When to de-prioritise it:

• You’re comparing insurers with very different premium levels (narrow policy = low complaints, but worse coverage).
• You need specific coverage that some insurers don’t offer (approval rates matter more).
• You’re buying a policy you hope you won’t claim under (focus on premium value and stability instead).

The real question: Does claim complaint volume predict your experience? 

Partially. It’s one signal in a sea of signals. An insurer with 50+ complaints might still handle your straightforward claim beautifully. An insurer with 5 complaints might reject your claim because your policy is narrow. Use this metric as one input in a more thorough evaluation, not as the decision itself.

The best health insurer for you depends on your coverage needs, budget, claim profile and policy features. Complaint volume should support your decision, not make it.

Next Steps

Claim complaint volume is just one of the factors that determine whether a health insurer is right for you. Before making a decision, compare it alongside claim settlement performance, policy coverage, waiting periods, exclusions, network hospitals and premium value.

If you’re comparing multiple health insurance plans and aren’t sure which insurer best fits your needs, our IRDAI-certified insurance advisors can help you evaluate them using real claims data and policy features, not sales targets.

Book a free consultation with an IRDAI-certified advisor.

Disclaimer: This article is for informational purposes only. Claim complaint data is taken from IRDAI Mandated Public Disclosures (NL-45) for FY 2025-26. Complaint data reflects formal escalations to the insurers of IRDAI and does not include informal resolutions. When choosing a health insurer, consult a licensed advisor for personalised recommendations. Algates Insurance is an IRDAI-registered Insurance Marketing Firm (IMF Code: IMF187250600920210470).