Why Ayush Claims Are Often Denied Despite Health Cover

Irdai directed insurers to treat Ayush at par with allopathy, but they continue to reject claims

- Aprajita Sharma

Chhattisgarh-based Moin Vanak, who suffers from diabetes, digestive issues and hypertension, turned to naturopathy for his persistent shoulder, knee and calf pain—as well as long-standing sleep issues. Hoping for sustained relief, he enrolled in a 10-day in-patient treatment at a NABH-accredited naturopathy hospital. But, despite having health insurance policy, he paid the expenses out of pocket and applied for reimbursement later.

To his surprise, the insurance claim was rejected. The insurer stated: "As per submitted documents, the patient was admitted primarily for diagnostic and evaluation purposes only," which doesn't meet the criteria for in-patient treatment under most policies.

Vanak has since submitted a doctor's justification stating that IPD or in-patient care was medically necessary in his case. However, the claim remains unresolved. "They're still refusing even though the hospital is NABH-accredited," he added. His experience reflects a growing problem with AYUSH insurance claims: a gap between regulatory intent and ground-level execution.

What the rules say

In January 2024, the Insurance Regulatory and Development Authority of India (Irdai) directed that all health insurance policies must cover AYUSH—Ayurveda, Yoga and Naturopathy, Unani, Siddha, and Homeopathy—treatments at par with allopathy. Earlier, policies often came with exclusions or sub-limits for AYUSH, which were to be removed.

Insurers have also been instructed to establish controls and standard operating procedures (SOPs) to: a) empanel AYUSH hospitals and day-care centers; b) include appropriate clauses in agreements with such hospitals; c) ensure standard treatment protocols; and d) detect and manage fraud or misuse.

Despite the guidelines, some policies retain certain exclusions. Star Health's comprehensive plan, for instance, has excludes yoga and naturopathy, while Niva Bupa's ReAssure 2.0 policy also excludes yoga treatments.