Nobody will mandate NHCX. Your regulator, your insurer and your data law will.

Ask a doctor, a hospital insurance desk or an insurer whether they use the National Health Claims Exchange, and the answer is no. Hospitals will not spend money to connect until insurers send real claims through it. Insurers will not send claims until hospitals are connected. No one has ordered anyone to do anything. So how does NHCX ever take off?

Not through one order from the Health Ministry. That is not coming. The push is coming through three other doors, and two of them are already open. But start with what is actually happening on the ground, because the official numbers hide it.

First, what we actually know about traction

NHCX handled its first claim in June 2024. A month later the Health Ministry said 34 insurers and TPAs were live, and about 300 hospitals were "ramping up to start sending their claims". Read that again. Insurers: live. Hospitals: getting ready to start. That is the whole problem in one government sentence. NHA had drawn the same line even earlier. In November 2023 it announced ten hospitals onboarded to the NHCX registry, and in the same release described their software clearing the first ABDM milestone as a step towards NHCX integration, not the finish.

Since then, most numbers you see come from software vendors quoting NHA's dashboard, and they contradict each other. So I went to the dashboard. Here is what it showed in the week of 21 September 2026.

Three things stand out.

First, NHCX already works, for government schemes. Almost 47,000 hospitals and 8.89 crore claim messages have gone through it for PMJAY and state schemes. Hospitals file those claims in NHA's own portal, TMS 2.0, and the exchange carries them to the state agency that pays. Look closely at that 47,000. India has only about 26,000 public hospitals in total, and PMJAY alone had 16,746 private hospitals in its network in February 2026. So the government row is full of private hospitals.

Second, private insurance has barely started. Twenty-seven months after launch: 867 hospitals and 30,246 claim messages. That is about 1,100 messages a month for the whole country. Those 867 hospitals are about 5% of the 16,746 private hospitals already sending scheme claims through the same exchange. Against India's estimated 44,000 private hospitals, it is closer to 2%. For scale, policyholders claimed ₹1,32,488 crore from health insurers in FY25, as Edition 75 showed from IRDAI's annual report. When people ask how NHCX will gain traction, this is the part they mean, and this is how far it has got.

Third, private insurers are connected but not using it. The dashboard shows 38 private integrators. India has about 35 insurers that sell health cover (27 general insurers and 8 health-only insurers, after Prudential HCL got its licence in July 2026) and 17 licensed TPAs. So most of them are connected. But 34 were already connected in July 2024. Two years added four. And 30,246 claim messages spread across 38 integrators is about 800 each since launch. Being connected is not the same as using it, on the insurer side too.

Now match that against the ground. I asked doctors, hospital insurance desks and insurers whether they use NHCX. Every answer was no. The dashboard says they are right. Thirty thousand messages across 38 insurers is about 30 a month each; a claims team handling lakhs of claims a year would never notice them. And 867 hospitals out of roughly 44,000 means that if you call ten private hospitals at random, the number that have ever sent a claim through the exchange is, on average, zero.

Independent research says the same. A WHO-supported study led by the eGov Foundation surveyed 22 organisations and interviewed ten more between September and October 2025: hospitals, insurers, TPAs, software vendors and government teams. Most placed themselves at the exploration or limited-pilot stage. Only national programmes and a few large vendors reported sustained use. Nearly two-thirds put lack of funding or business incentives among their top three barriers, and the authors call adoption uneven and largely compliance-driven. One implementer's line sums it up: FHIR is hard to implement, why should we take the trouble?

There is one more reason your insurer contact may say no and still be wrong about their own company. Private claims often reach the exchange through a TPA, not the insurer. Medi Assist, which administers about a fifth of India's health premiums, told investors in August 2024 that it had processed live claims through NHCX. So an insurer's claims desk can be truthfully unaware while its TPA is connected. The exchange sits two layers below the person you asked. Even so, all of that plumbing has produced 30,246 private claim messages in 27 months.

The eight crore government messages are real, but nobody on the ground calls them NHCX either. A PMJAY hospital files its claims in TMS 2.0, the scheme's own portal. The exchange is the plumbing behind it, invisible to the billing desk. So a mid-tier private hospital in Lucknow or Coimbatore that treats PMJAY patients is already sending claims through NHCX every day without knowing it, while its Star Health and HDFC ERGO claims still leave the building as PDFs. The flagship urban corporate hospital, which often runs little or no PMJAY because the package rates do not cover its costs, has not touched the exchange at all. Neither has the 30-bed nursing home.

So the honest position is this. The exchange works, for the payer that built the connection at both ends. For the private market that pays ₹1.08 lakh crore a year in group and individual health premiums, nothing has changed. As I wrote about ABHA in Edition 61, the headline number and the number that matters are rarely the same.

That is where we stand. Now the three doors.

India's new data privacy law, the DPDP Act, got its rules on 13 November 2025. They arrive in three steps. The Data Protection Board came first. Consent Managers register from 13 November 2026. And the duties that carry penalties, for every hospital, insurer, TPA and software company that handles patient data, start on 13 May 2027. From that date, failing to keep patient data secure can cost up to ₹250 crore. Failing to report a data breach, up to ₹200 crore.

Now think about what a cashless claim is. A patient's diagnosis, treatment notes, bills and identity, put together by a hospital, passed to a TPA, decided by an insurer. Today that bundle moves as scanned PDFs on portals, email and messaging apps, and hospitals find out what happened by phone. Under the new law, every organisation on that route is legally responsible for that data.

NHCX is a post office, not a storeroom. The claim's medical and financial details are encrypted end to end. The exchange reads only the address. The law never names NHCX. It simply makes the old way dangerous. That pushes harder than any circular.

India's first compulsory ABDM rule did not come from the Health Ministry or the National Health Authority. It came from the National Medical Commission, the body that regulates medical colleges. And the reason had nothing to do with digital health. It was about colleges inflating patient numbers to pass inspections.

In June 2024, NMC ruled that from the 2025-26 inspection year, only patients verified with an ABHA ID would count as real patients. That count decides how many seats a college gets and whether it keeps its recognition. In March 2026, NMC told every college to link its hospital software to the ABDM portal within 15 days, reminding them that having an HMIS was already compulsory under its 2023 rules. On 17 July 2026, NMC's Secretary ordered every college hospital to run ABDM-compliant software immediately. Nine days later, 18 medical colleges in Madhya Pradesh got notices: fix the gaps in 15 days or face action, including losing recognition.

That is 836 medical colleges, on the list NMC published on 9 September 2026, every one with a teaching hospital, now on a compulsory ABDM path. The penalty is the one no college can survive: losing its seats. NMC did this to stop fake patient counts. The effect on digital health is the same.

Now the regulator everyone does watch. IRDAI's circular of 8 June 2023 advised insurers and TPAs to adopt NHCX. Its May 2024 Master Circular said insurers may endeavour to get hospitals onto it. Advised. May. Endeavour. That is the language of three years of voluntary adoption.

But the same Master Circular did something harder. It requires insurers to approve cashless treatment within one hour and final discharge within three hours. Those are binding rules. No insurer can meet a one-hour clock across thousands of hospitals on scanned PDFs. IRDAI has ordered the result and left the industry to work out that NHCX is the only pipe wide enough to deliver it.

In August 2026 the language changed. A Parliamentary committee recommended that insurers, TPAs and hospitals be made to join NHCX, and said IRDAI should issue strict directions to hospitals to connect their billing systems and fine them for delays. The same month, IRDAI's own health insurance committee, chaired by IRDAI's chairman, met for the third time and discussed rewards for joining NHCX, paying through it and settling faster.

The Finance Ministry has joined in too. On 13 November 2025 the Financial Services Secretary chaired a meeting of the General Insurance Council, AHPI, Max, Fortis, Apollo and insurers including New India, Star Health and Bajaj Allianz, and asked both sides to speed up onboarding to NHCX, alongside standard treatment protocols and common empanelment.

From "may endeavour to" in 2024 to "penalties for delays" in 2026 took two years. One word is still missing: shall. When the next IRDAI health circular says insurers shall use the standard, probably worded as "the prescribed e-claim standard through the designated exchange" rather than naming NHCX, the insurer side flips overnight. A licensed insurer cannot opt out of a rule.

The theory is simple. Insurers make NHCX a condition for staying in their cashless network. Hospitals agree because cashless patients matter more than the cost of connecting. The government has already put money behind this idea. NHA's original 2023 scheme paid hospitals ₹500 per claim, or 10% of the claim, for every insurance claim sent through the exchange. In April 2026 that was reportedly changed to ₹200 per claim, only for PMJAY claims sent through NHCX, with a further condition from July that the hospital's software must meet the latest ABDM standards or earn nothing. Three moves at once: the rate was cut, the money was limited to the scheme NHA itself pays for, and the software bar was raised.

Here is the catch. In India, insurers do not hold the power in that contract. In August 2025 the Association of Healthcare Providers of India, with 15,200 member hospitals, told its North Indian members to stop cashless treatment for Bajaj Allianz customers from 1 September because payment rates had not been revised for years. It served a similar notice on Care Health. Within a week, Bajaj Allianz agreed to the hospitals' terms and cashless was back.

And it does. Hospitals say waiting 30 to 45 days for private insurance payments is one of their biggest complaints. PMJAY's own rules require payment within 15 days for in-state hospitals and 30 for out-of-state cases, and those claims already travel through the exchange. When NHA reviewed its programmes in July 2026, what it highlighted about NHCX was faster payment of approved PMJAY claims and better cash flow for hospitals. A digital channel that gets hospitals paid sooner is worth more to a hospital CFO than any government incentive. The insurer mandate will not arrive as a demand. It will arrive as a payment term. And the proof that the pipe can carry it is already on the dashboard: 8.89 crore claim messages, all for a payer that chose to use it.

That covers the hospital's reason. Insurers have just been handed one of their own. From 1 April 2026, IRDAI's new Fraud Monitoring Framework requires every insurer to run a formal fraud-risk programme and to feed the Insurance Information Bureau's fraud technology framework, which will keep a repository of blacklisted hospitals and vendors. BCG and Medi Assist estimate that ₹8,000 to ₹10,000 crore of claim payouts leak every year through fraud, waste and abuse, and their report names ABDM and NHCX as the real-time data plumbing to fix it. You cannot run fraud analytics on scanned PDFs. So the insurer now wants what the hospital wants, standard digital claims, for a different reason. One caution: IRDAI's rules name IIB, not NHCX, and insurers can buy fraud analytics elsewhere. NHCX only wins this if it becomes the cheapest place to get the data.

The best precedent is PMJAY itself. No private hospital was ever ordered to join. 16,746 did, because the scheme brings patients and pays within 15 days. Private hospitals now account for 6.74 crore of its 11.69 crore admissions. Nobody mandated PMJAY on the private sector. Economics did.

So how does traction actually happen?

Not with one switch. In steps, like a staircase: the biggest and most tightly regulated players first, small clinics last. India has done this before. GST e-invoicing began with companies above ₹500 crore turnover in October 2020 and lowered the bar, notice by notice, to ₹5 crore by August 2023. Make the rule for the group you can regulate. Then widen it.

What would prove me wrong

• The private claim counter on NHA's dashboard is still a five-digit number in September 2027.
• IRDAI's committee stops at rewards and never recommends a rule.
• NMC's Madhya Pradesh notices end in extensions rather than action.
• DPDP enforcement in healthcare is delayed or watered down before May 2027.

If three of those four happen, the staircase stalls on its first step. My read is that none of them will.