The Missing Document Engine ensures every ordered test, specialist referral, and recommended follow-up has a corresponding result in the NSTP file.

Track Every Referral to Its Result

# The Referral That Promised a Test Result That Never Arrived in the Underwriting File

Missed prescription follow-up is one of the least discussed but most consequential gaps in NSTP underwriting. A physician writes a referral for a cardiac stress test. The referral letter is in the file. The stress test result is not. The underwriter reviews the documents, sees no abnormal cardiac findings in the submitted records, and approves the case. Six months later, a claim arrives for acute coronary syndrome.

The referral was the signal. The absence of the result was the risk. And the underwriting process had no mechanism to track one to the other.

Industry analysis for 2025 indicates that 15-20% of NSTP cases contain at least one referral or ordered test for which the corresponding result document was never submitted. Each of these gaps represents risk that exists in the medical record but never reaches the underwriter's decision. The question is not whether these gaps exist. The question is whether the underwriting workflow is designed to detect them.

## Why Do Referral Gaps Create Unquantified Risk in NSTP Cases?

Referral gaps create unquantified risk because a physician orders a test only when clinical suspicion exists, and the absence of the result means the suspicion was either confirmed (and withheld) or never resolved, both of which leave the insurer exposed.

### 1. The Clinical Logic of Referrals

Physicians do not order tests randomly. A cardiologist refers a patient for a stress test because the clinical presentation suggests possible coronary disease. A nephrologist orders a renal biopsy because the creatinine trend and urine protein suggest progressive nephropathy. An oncologist orders a PET-CT because a mass was found on routine imaging.

Every referral implies a clinical hypothesis. The test result either confirms or rules out that hypothesis. When the result is absent, the hypothesis remains untested, and the risk remains unpriced.

| Referral Type | What It Implies | Risk If Result Missing |
| --- | --- | --- |
| Cardiac stress test | Suspected coronary disease | Unquantified cardiac risk |
| Renal biopsy | Progressive nephropathy suspected | Unknown renal prognosis |
| PET-CT | Mass or suspected malignancy | Unscreened cancer risk |
| HbA1c follow-up | Diabetes monitoring | Uncontrolled diabetes possible |
| Liver biopsy | Chronic liver disease staging | Unknown fibrosis stage |
| Pulmonary function test | Suspected COPD/asthma | Unquantified respiratory risk |

### 2. The Two Possible Explanations

When a referral exists but the result does not, only two explanations are plausible:

The test was completed, the result was unfavorable, and the applicant (or agent) chose not to include it in the submission. This is deliberate [silent non-disclosure](/blog/silent-non-disclosure), where the concealment is achieved not by falsifying documents but by selectively omitting them.

Alternatively, the test was never completed, meaning the clinical suspicion was never resolved. In this case, the insurer is underwriting a risk that even the treating physician considered uncertain enough to warrant investigation.

Neither explanation supports policy issuance at standard terms.

### 3. The Volume of Undetected Gaps

At 15-20% of NSTP cases containing at least one missing follow-up, and with Indian insurers processing 30,000-80,000 NSTP cases annually, the total number of policies issued with unquantified referral gaps runs into thousands per year per insurer. Each represents a potential claim that was foreseeable at underwriting but invisible to the process.

> **A Missing Result Is Not a Missing Document. It Is a Missing Risk Signal.**
>
> [Talk to Our Specialists](https://insurnest.com/solutions/#lets-get-in-touch)
>
> Visit [InsurNest](https://insurnest.com) to learn how Underwriting Risk Intelligence helps insurers detect hidden NSTP risk before policy issuance.

## What Types of Follow-Ups Should Underwriters Track?

Underwriters should track specialist referrals, ordered diagnostic tests, recommended follow-up consultations, prescription modifications referencing pending results, and discharge summary recommendations for post-discharge testing.

### 1. Specialist Referral Letters

When a general physician refers a patient to a cardiologist, endocrinologist, or nephrologist, the referral letter is a signal that the GP identified a concern beyond their scope. The specialist's consultation report and any tests the specialist ordered must be in the file. If the referral exists but the specialist report does not, the gap needs to be flagged.

### 2. Ordered Diagnostic Tests

Physician notes and consultation reports frequently reference tests that have been ordered: "Advised TMT," "HbA1c to be repeated in 3 months," "MRI brain ordered." Each of these represents a test that should produce a result document. If the result is not in the NSTP file, the [missing document engine](/blog/missing-document-engine) should flag it.

### 3. Prescription Modifications With Pending Context

Sometimes a prescription is modified with a note like "increased metformin to 1500mg, pending HbA1c result" or "switch to insulin if HbA1c > 8.0." These notes indicate that a test result is expected to drive the next treatment decision. The absence of that test result means the treatment escalation decision was never documented.

### 4. Discharge Summary Follow-Up Recommendations

Discharge summaries from hospital stays routinely include follow-up recommendations: "Review in 2 weeks with repeat CBC," "Echocardiography in 6 weeks," "Follow-up CT abdomen in 3 months." When the discharge summary is in the NSTP file but the recommended follow-up results are not, the gap is significant. It may indicate a condition that was treated acutely but never confirmed as resolved.

For related analysis of how [discharge summary fraud](/blog/discharge-summary-fraud) compounds the missing follow-up problem, see our detailed review.

## How Does the Missing Document Engine Track Referral-to-Result Chains?

The Missing Document Engine tracks referral-to-result chains by extracting every clinical instruction from every document, building a dependency map, and verifying that every instruction has a corresponding result document in the submission.

### 1. Instruction Extraction

The engine reads every document in the NSTP case and extracts clinical instructions using natural language processing. It identifies phrases like "advised," "ordered," "referred to," "recommended," "to be repeated," and "follow-up with." Each extracted instruction is classified by type (diagnostic test, specialist referral, follow-up consultation, procedure) and expected timeline.

### 2. Dependency Mapping

Each instruction creates a dependency: if Test X was ordered, Result X must exist. If Referral Y was made, Specialist Report Y must exist. The engine builds a complete dependency map across the entire document set and checks each dependency against the submitted documents.

### 3. Gap Flagging

When a dependency has no matching result document, the engine generates a flag with:

| Flag Component | Example |
| --- | --- |
| Source document | Physician consultation note, page 3 |
| Instruction text | "Advised TMT and 2D Echo" |
| Expected result | TMT report and Echocardiography report |
| Status | TMT report: Present. Echo report: Absent |
| Risk implication | Cardiac structural assessment incomplete |

This structured flag gives the underwriter a precise action item: request the missing document before proceeding with the decision. It transforms [missing signals in underwriting](/blog/missing-signals-underwriting) from invisible gaps into visible, actionable items.

## What Happens When Missed Follow-Ups Are Not Detected?

When missed follow-ups are not detected, the insurer issues a policy on a risk that the treating physician considered uncertain, and the claim arrives for exactly the condition the missing test would have revealed.

### 1. The Claim Scenario

A 42-year-old male applies for a health insurance policy with a sum assured of Rs 25 lakhs. The submitted documents include a general physician consultation noting "mild chest discomfort on exertion, advised TMT." The TMT report is not in the file. The underwriter reviews the available documents, sees no cardiac abnormality in the submitted ECG, and issues the policy at standard rates.

Fourteen months later, the policyholder files a claim for coronary angioplasty. The investigating officer discovers that the TMT was completed, showed significant ST depression, and the patient was already under a cardiologist's care at the time of application. The TMT report was deliberately excluded from the submission.

### 2. The Cost Chain

The claim amount is Rs 8 lakhs. The investigation costs Rs 45,000. If the insurer repudiates, the legal and regulatory costs add Rs 2-3 lakhs. If the insurer pays, the loss ratio absorbs the full Rs 8 lakhs on a risk that should have been loaded by Rs 15,000-20,000 per year or excluded for cardiac conditions.

Had the [missing document engine](/blog/missing-document-engine) flagged the absent TMT result at the underwriting stage, the underwriter would have requested the report, discovered the coronary risk, and applied appropriate terms. The total cost of detection: zero additional, since it is part of the automated check. The total cost of non-detection: Rs 8-11 lakhs.

### 3. The Portfolio Impact

Multiply this scenario across the 15-20% of NSTP cases with missing follow-ups, and the portfolio-level impact becomes visible in the [loss ratio](/blog/health-insurance-loss-ratio-india). Each undetected gap contributes to [adverse selection](/blog/adverse-selection-india) as under-priced risks accumulate in the book.

> **Stop Approving Cases With Unanswered Clinical Questions**
>
> [Talk to Our Specialists](https://insurnest.com/solutions/#lets-get-in-touch)
>
> Visit [InsurNest](https://insurnest.com) to learn how Underwriting Risk Intelligence helps insurers detect hidden NSTP risk before policy issuance.

## How Can Insurers Implement Follow-Up Tracking in Their Underwriting Workflow?

Insurers can implement follow-up tracking by deploying the Missing Document Engine as part of Underwriting Risk Intelligence, which automatically maps every referral and ordered test to its result and flags gaps before the underwriter makes a decision.

### 1. Automated Dependency Tracking

The Missing Document Engine integrates into the NSTP workflow at the document intake stage. As documents are uploaded, the engine reads each one, extracts clinical instructions, and builds the dependency map. By the time the underwriter opens the case, the gap analysis is complete and the missing items are listed in the [underwriting decision brief](/blog/underwriting-decision-brief).

### 2. Structured Follow-Up Requests

When gaps are identified, the system generates structured follow-up requests that can be sent to the applicant or agent. The request specifies exactly which document is missing, which source document references it, and why it is required. This eliminates the ambiguity of generic "additional documents required" communications.

### 3. Decision Protection

Until every flagged gap is resolved, the case is marked as incomplete. The underwriter cannot issue a final decision without either receiving the missing document or explicitly documenting why the gap does not affect the risk assessment. This creates an [audit trail](/blog/irdai-audit-trail) that satisfies IRDAI's evidence-backed underwriting requirements and protects the insurer in case of future [claim defensibility](/blog/claim-defensibility-india) challenges.

## Frequently Asked Questions

**What is a missed prescription follow-up in underwriting?**
A missed prescription follow-up occurs when a physician's referral or prescription recommends a diagnostic test, specialist consultation, or follow-up procedure, but the corresponding result or report is absent from the NSTP submission file.

**Why are missed follow-ups dangerous for insurers?**
A missing follow-up result typically means one of two things: the test was done and the result was unfavorable (and deliberately withheld), or the test was never done and the risk remains unquantified. Both scenarios represent unpriced risk in the portfolio.

**How does the Missing Document Engine detect referral gaps?**
The Missing Document Engine reads every document in the NSTP case, extracts every referral, ordered test, and recommended follow-up, then checks whether the corresponding result document exists in the file, flagging every gap.

**What percentage of NSTP cases have missing follow-up documents?**
Industry analysis indicates that 15-20% of NSTP cases contain at least one referral or ordered test for which the result document is not submitted, representing a significant pool of unquantified risk.

**Can a missed follow-up indicate non-disclosure?**
Yes. When a physician orders a test for a suspected condition and the result is absent, the most likely explanation is that the result confirmed the suspicion, and the applicant chose not to submit it. This is a form of silent non-disclosure.

**What types of referrals should underwriters track?**
Underwriters should track specialist referrals, ordered diagnostic tests (imaging, biopsies, stress tests), recommended follow-up consultations, prescription modifications that reference pending test results, and discharge summary recommendations.

**How does missed follow-up detection improve underwriting accuracy?**
By ensuring every ordered test and referral has a corresponding result in the file, underwriters eliminate the blind spots where significant diagnoses can hide, reducing the probability of issuing policies on unquantified risk.

**What is the difference between a missing document and a missed follow-up?**
A missing document is any required document not in the file. A missed follow-up specifically refers to a test, referral, or procedure that was ordered or recommended within the submitted documents but whose result was never submitted.

## Sources

- [Insurance Sector Faces Rs 10,000 Crore Annual Leakage - The420.in](https://the420.in/india-health-insurance-fraud-10000-crore-leakage-ai-governance/)
- [IRDAI Insurance Fraud Monitoring Framework Guidelines 2025 - TaxGuru](https://taxguru.in/corporate-law/irdai-insurance-fraud-monitoring-framework-guidelines-2025.html)
- [AI Underwriting Insurance in 2026: Risk Transformation - AthenaGT](https://athenagt.com/ai-underwriting-insurance-risk-assessment-2026/)
- [India Health Insurance Non-Disclosure Risk to Insurer Solvency - WhalesBook](https://www.whalesbook.com/news/English/insurance/India-Health-Insurance-Non-Disclosure-Risk-to-Insurer-Solvency/6995914ed25eafd9cdfd563b)
- [Playbook to Unlocking the Power of IRDAI's 2025 Insurance Fraud Monitoring Framework - Ankura](https://ankura.com/insights/playbook-to-unlocking-the-power-of-irdais-2025-insurance-fraud-monitoring-framework)

Posts tagged with#Missing Documents

Missed Prescription Follow-Up in India: 15-20% NSTP Cases at Risk