Transforming Health Claims Ecosystem
The health insurance industry in India is at a tipping point. Despite rapid advances in fintech and insurtech, one area remains painfully outdated: health claims processing. Customers face long turnaround times, insurers struggle with manual adjudication costs, and the entire ecosystem suffers from fraud, waste, and abuse (FWA) running into millions of dollars.
At the India Insurtech Summit 2025, Praish Rawat, Head of Products for Health Insurance at Perfios & IHX, shared a bold vision for fixing this broken system — not with incremental tweaks, but with a fundamental transformation.
- Why Health Claims Are Broken Today
Let’s face it: health claims in India don’t inspire confidence. Patients don’t trust insurers, insurers don’t trust providers, and providers are caught in an endless back-and-forth of paperwork, errors, and disputes.
Some of the key challenges include:
- Delayed Turnaround Times – Claims often stretch across weeks, leading to frustration at the most vulnerable time for patients.
- Manual Adjudication – Reliance on human-driven checks increases costs and inconsistencies.
- Lack of Structured Data – Unstandardized inputs make automation, analytics, and fraud detection difficult.
- Fraud, Waste, and Abuse – Inefficiencies and loopholes create systemic financial leakage.
It’s no surprise that the ecosystem feels opaque, slow, and fragmented.
- Perfios + IHX: A Strategic Shift
In early 2025, Perfios acquired IHX, India’s largest health information exchange platform. But this wasn’t just a business acquisition — it was the merging of two complementary strengths:
- IHX’s Scale & Data – Access to 30,000+ healthcare providers and over 4 million processed claims annually, enabling digitization at the source.
- Perfios’ AI-Powered aClaim Platform – Real-time decisioning, fraud detection, and advanced analytics layered on structured data.
Together, they form an end-to-end claims ecosystem that enables:
- First-time-right claim submissions
- Automated fraud and error detection
- Transparent, explainable adjudication
- 90% reduction in turnaround time
- 75% reduction in manual effort
- Over 5% savings in fraud and abuse detection
- 100% traceable audit trails
This isn’t theory. These solutions are already live, scaling across India and global markets.
- Reimagining the Claims Journey
Imagine a health claims process where every step is digitized, validated, and transparent:
- Hospitals initiate claims seamlessly through a unified portal, with pre-verified policy and package rates.
- AI-Powered Document Classifiers automatically detect missing paperwork, reducing costly queries.
- Real-Time Decisioning Engines validate claims instantly against policy rules, treatment protocols, and historical benchmarks.
- Insurers see claims on a unified adjudication dashboard with AI-driven insights into fraud, waste, and discrepancies.
- Providers & Patients get faster, clearer resolutions — with every decision traceable and explainable.
This is not a vision for 2030. This is already happening today.
- Building Trust in a Trust-Deficient Ecosystem
Perhaps the biggest impact of this transformation isn’t just speed or efficiency — it’s trust.
For decades, mistrust between providers and payers has slowed claims and hurt customer experiences. By digitizing data at source and making every decision explainable, Perfios + IHX are restoring confidence in the system.
The result:
- Providers trust payers because claims are processed with structured, consistent data.
- Payers trust providers because AI-powered analytics flag fraudulent or excessive claims.
- Customers trust the system because they see transparency and faster resolutions at the time they need it most.
- The Future of Health Claims
With AI-powered, self-learning systems already achieving 98%+ accuracy, the future looks promising. As adoption grows, India’s health claims ecosystem could become:
- Near-Real-Time – From weeks of waiting to decisions in hours.
- Frictionless – Minimal back-and-forth between hospitals and insurers.
- Resilient & Scalable – A digital-first backbone capable of handling millions of claims without bottlenecks.
This is not just about claims automation — it’s about reshaping the very foundation of health insurance in India.
- Final Thoughts
Health claims may have been the weakest link in the insurance chain for years, but that’s changing fast. By combining IHX’s provider network and data scale with Perfios’ AI-driven adjudication and fraud analytics, the industry is moving towards a system that is faster, transparent, efficient, and trustworthy.
For insurers, this means reduced costs and better fraud control.
For providers, it means less paperwork and faster settlements.
For customers, it means peace of mind when they need it most.
The health claims ecosystem is finally evolving from frustration and opacity to trust and efficiency — and this transformation is already underway.
Speakers
