Insurance claim automation looks like a data problem. But the more I looked into it, the more I felt it was actually a trust problem.

There are three parties involved: the policyholder, the hospital and the insurer. And each one has a reason to not be the person who made a mistake.

While building software for small hospitals at HealthFirst AI, I kept running into the same thing. Patients in non-cashless setups often had no idea who they were supposed to notify, the insurer or the TPA, or even how to do it.

Seeing patients and their families running around trying to figure this out, I had a simple thought.

What if there was just a QR code at the hospital? Scan it, enter your policy details, and it routes the notification to the right place and gives you a reference ID.

No claims. No cashless authorization. Just getting the hospitalization officially on record.

I went pretty deep into India’s NHCX infrastructure. I was specifically trying to figure out whether a policyholder could get a formal, timestamped and auditable record of notifying their insurer about a hospitalization at a non-network hospital.

The answer was interesting.

The HCX Protocol already has a role for something called a Beneficiary Service Platform (BSP), which could potentially enable this. But the BSP role isn’t active in NHA’s live production network yet.

So the clean, direct version of the product doesn’t really have a v1 path today.

But there is another way.

A hospital-assisted TSP model could route the notification through systems hospitals already have. It isn’t the ideal version I had in mind, but it can actually be built with the infrastructure that exists today instead of waiting for the infrastructure in the spec to become reality.

Then I found something that changed how I looked at the problem.

Insurers can’t necessarily reject an otherwise genuine claim just because the policyholder informed them late. IRDAI has guidance around this, and the Supreme Court has also relied on this principle.

So the real value of a “proof of notification” product isn’t really about closing some legal loophole.

That loophole is already mostly closed.

The bigger problem is much simpler.

When someone is dealing with a hospitalization, nobody has the bandwidth to think about whether they notified the insurer at the right time, sent the right thing, or have proof that they actually did it.

So maybe the product isn’t really about automating insurance claims.

It’s about giving someone a simple record that says:

You did your part.

And when you’re already dealing with a stressful situation, knowing that can be worth a lot.

A few terms

NHCX (National Health Claims Exchange) India’s infrastructure for exchanging health-insurance claim information digitally.

HCX (Health Claims Exchange) The protocol that defines how different systems can exchange health-claim information.

BSP (Beneficiary Service Platform) The part of the system meant to represent the policyholder or beneficiary.

TSP (TPA Service Provider) A service that helps connect TPAs and other players to the health-claims system.

TPA (Third Party Administrator) A company that helps insurers manage health-insurance claims and coordinate with hospitals.

IRDAI (Insurance Regulatory and Development Authority of India) The regulator that oversees India’s insurance industry.