When a financier looks at a health insurance claim, they need to answer five basic questions before they can make a decision. Not complicated questions. Not questions that require new data. Questions that any functioning information system should be able to answer in seconds.
Today, none of them have reliable answers.
Is this claim authentic?
A hospital submits a claim. The claim says a patient was treated, a procedure was performed, a policy was in force. Is any of that actually true?
In most industries, document trails answer this question. A delivery receipt. A signed purchase order. A GST filing that proves a transaction happened. These exist independently of the party presenting the document. A third party can verify them.
In healthcare, the equivalent trail exists inside insurer systems, TPA portals, and hospital management software. It does not exist in a single place that a third party can query. A claim document is whatever the hospital says it is until an insurer adjudicates it. Before adjudication, there is no independent source of truth. After adjudication, the confirmation lives in the insurer's system and is accessible, if at all, only through bilateral inquiry.
There is no standardised, machine-readable, tamper-evident record of a claim's existence and clinical validity that any authorised party can check without calling someone.
Is this claim approved, and for how much?
Authentic is not the same as approved. An insurer reviews a submitted claim, checks policy coverage, validates clinical documentation, applies deductions, and arrives at an approved amount. That approved amount is often different from the billed amount. Deductions for non-covered items, protocol deviations, and administrative shortfalls are routine.
A hospital billing Rs 1.5 lakh may receive approval for Rs 1.2 lakh. The hospital's own records may show the billed figure. The approval letter, if it exists in machine-readable form at all, may be a PDF in an email.
There is no single authoritative source where an external party can confirm: this specific claim, from this specific hospital, was approved by this insurer, on this date, for this exact amount.
Is this claim still unpaid?
An approved claim is not an unpaid claim. Insurers settle claims continuously. A claim approved three months ago may have been paid last week. The hospital may not have reconciled it yet. The information about whether a given claim has been paid sits on the insurer's treasury system, and it does not flow anywhere in real time.
If you want to know whether an approved claim is still outstanding, you ask the hospital. The hospital tells you what their books show. Their books may be accurate. Or reconciliation may be three weeks behind. There is no third-party system that answers this question independently of the hospital's assertion.
Has this claim already been presented to someone else?
A hospital with ten approved claims and a cash problem can, in theory, present the same claim to two different parties on the same day. Both parties believe they are the only one looking at it. Neither can verify otherwise. There is no registry of which claims have been presented for financing, to whom, and when. There is no mechanism that rejects a second attempt to use a claim that has already been assigned.
This is not a theoretical risk. It is the natural consequence of a market where each transaction happens bilaterally, with no shared ledger, no central record of what has been pledged, and no system that any party can query to confirm exclusivity.
When does the insurer actually pay?
Even when everything else is resolved, the settlement date is unknown. An insurer approves a claim today. When will it pay? The approval document does not say. There is no contractual obligation on the insurer to communicate a payment date at the point of approval. Different claims from the same insurer may settle in 30 days or 180 days, depending on internal batch cycles, state government disbursement schedules, or treasury decisions that have nothing to do with the hospital.
The hospital does not know when to expect the money. The insurer knows its own schedule but does not publish it. No one outside the insurer has access to a confirmed settlement timeline for any specific approved claim.
What this adds up to
These are not complicated questions. They are the minimum information any party needs to make a decision about a health insurance claim with any degree of confidence.
Claim exists and is genuine. Approved amount confirmed. Not yet paid. Not already pledged elsewhere. Settlement date known.
None of these require new data to be generated. The data exists. It lives in insurer systems, TPA platforms, hospital management software, and state health authority dashboards, spread across dozens of systems that do not talk to each other, in formats that are not standardised, accessible only through bilateral requests that take days and produce inconsistent results.
The problem is not that the information does not exist. The problem is that it has never been brought together in one place, in a form that any authorised party can access, verify, and rely on.
Until that changes, every decision made about a health insurance claim depends on someone's word rather than a system's record. That is a fragile foundation for a market of any size.