General Insurance Council defends fever admission advisory framework

Insurance body says the advisory follows ICMR and health ministry guidelines, aims to curb unnecessary hospital admissions and does not restrict doctors' clinical autonomy

The General Insurance Council (GIC) on Monday defended its advisory on admission criteria for fever and infectious diseases, saying the framework is based on Indian Council of Medical Research (ICMR) and Ministry of Health and Family Welfare (MoHFW) guidelines and is aimed at reducing unnecessary hospitalisations, not restricting doctors’ clinical autonomy.

 

The council said the advisory is intended to promote evidence-based healthcare practices and protect patients from unnecessary costs, amid concerns raised by sections of the medical fraternity.

 

S Prakash, chief executive officer, Health Insurance Ecosystem and Strategic Partnerships, General Insurance Council, said the advisory was developed in response to a rise in avoidable hospital admissions and misuse of health insurance coverage, rather than as an attempt to interfere with doctors’ decision-making.

 

“Clinical autonomy remains paramount. The advisory is not a rule book but a framework for appropriate, evidence-based practice,” Prakash said.

 

According to GIC data, health claims settled by insurers reached ₹94,247.6 crore in 2024-25, with cashless admissions accounting for 66.4 per cent of the volume. The council said it has observed a significant increase in claims involving admissions for minor fever cases, unnecessary investigations and prolonged hospital stays that do not align with established clinical practices.

 

The council said such trends increase healthcare costs and contribute to rising insurance premiums for policyholders.

 

The council said the advisory is based on clinical guidelines issued by public health institutions, including the Indian Council of Medical Research, the Ministry of Health and Family Welfare, and the National Vector Control Programme. The council clarified that it has not created independent medical standards but has aligned insurance practices with existing government-backed healthcare frameworks.

 

“By referencing established guidelines, we ensure that insurance coverage reinforces national health policy rather than deviating from it,” the council said.

 

GIC also highlighted that similar approaches are followed internationally, where insurers and public healthcare systems refer to established clinical guidelines while determining appropriate care pathways.

 

The council stressed that doctors would continue to have the authority to admit patients whenever medically justified. If a treating physician chooses to deviate from the advisory’s suggested pathway, the decision can be supported through clinical documentation and reasoning.

 

“True clinical autonomy includes the ability to deviate from guidelines when clinically justified, with appropriate documentation and accountability,” Prakash said.

 

The insurance body said unnecessary admissions can expose patients to additional risks, including hospital-acquired infections, medication-related complications and avoidable financial burden. It added that rationalising admissions would help ensure hospital resources remain available for patients requiring inpatient care.

 

The council invited feedback from doctors, hospitals and medical associations, provided such inputs are supported by clinical evidence, and said its objective is to create a sustainable health insurance ecosystem that balances patient protection, affordability of insurance coverage and evidence-based medical care.