Health Insurance Claim Guide: Cashless, Reimbursement and What to Do If It Is Rejected
In a network hospital, ask the insurance desk for cashless pre-authorisation. IRDAI’s 2024 health circular says insurers should decide a cashless request within 1 hour and give final authorisation within 3 hours of the hospital’s discharge request. For reimbursement, pay first, submit the documents, and the insurer should settle within 15 days of submission.
- Cashless or reimbursement: which applies?
- Cashless claim: step by step
- Reimbursement claim: step by step
- Documents for a health claim
- Why the payout can be lower than the bill
- Why health claims get rejected, and what to do
- Your rights under IRDAI rules
- Before you need it: a short checklist
- Frequently asked questions
Cashless or reimbursement: which applies?
| Cashless | Reimbursement | |
|---|---|---|
| Where | Network hospital | Non-network hospital, or when cashless is not available |
| Who pays the hospital | The insurer or TPA, directly | You pay first, then claim |
| IRDAI timeline | Decision on authorisation within 1 hour; final authorisation within 3 hours of the discharge request | Settlement within 15 days of submission |
| Watch for | Non-payable items, co-payment, room-rent limit | Original bills, deadline for submission, complete documents |
Cashless claim: step by step
- Show your health card and policy details at the hospital’s insurance or TPA desk.
- For planned treatment, ask the hospital to send the pre-authorisation request before admission. In an emergency, inform the insurer as soon as you can.
- The hospital sends the diagnosis, treatment plan and medical records.
- The insurer or TPA approves, queries or rejects the request.
- Before discharge, make sure the final authorisation is obtained.
- Check the final bill for non-payable items, deductible and co-payment.
- Keep the discharge documents and the final settlement details.
Reimbursement claim: step by step
- Pay the hospital bill and collect every original bill and receipt.
- Get the discharge summary.
- Collect investigation reports, prescriptions and pharmacy bills.
- Fill in the claim form completely and sign it.
- Submit the claim through the insurer’s prescribed process, within the time limit in your policy.
- Keep the submission acknowledgement and claim number.
- Answer any insurer query in writing and keep a copy.
Documents for a health claim
| Document | Details |
|---|---|
| Claim form | Fully filled and signed |
| Policy or health card | Policy number |
| Discharge summary | Diagnosis and treatment |
| Final hospital bill and receipts | Itemised, with payment proof |
| Investigation reports | Blood tests, X-ray, MRI, CT scan |
| Prescriptions and pharmacy bills | Medicines with prescriptions |
| Implant invoice | If applicable |
| KYC and bank proof | As the insurer requires |
Why the payout can be lower than the bill
- Waiting periods. Initial, specific-disease and pre-existing-disease waiting periods apply separately.
- Room-rent limit. If you take a costlier room, other charges can be reduced in proportion.
- Co-payment. You bear a fixed share, such as 10% or 20%, of every eligible claim.
- Sub-limits. Some treatments or diseases have a monetary cap.
- Non-payable items. Consumables and some administrative charges are not covered.
- Deductible or exhausted sum insured. The cover can run out within the year.
Why health claims get rejected, and what to do
| Reason | What to do |
|---|---|
| Policy inactive or premium unpaid | Check the renewal status and any grace period before you apply |
| Treatment is an exclusion | Ask for the exact clause in writing |
| Waiting period not completed | Check the policy start date and the period that applies to your condition |
| Non-disclosure of medical history | Provide records; under IRDAI rules rejection needs to be reasoned and documented |
| Medical necessity disputed | Ask for the insurer’s medical reasoning and get your treating doctor’s supporting note |
| Sub-limit or co-payment applied | Ask for a deduction-wise calculation |
Do not accept a phone call as the final answer. Ask for the written rejection letter with the exact policy clause and the medical reason, then follow our grievance guide.
Your rights under IRDAI rules
- Cashless authorisation: decision within 1 hour of the request, and final authorisation within 3 hours of the hospital’s discharge request (IRDAI Master Circular on Health Insurance Business, 29 May 2024).
- Reimbursement: settlement within 15 days of submission (IRDAI Master Circular on Protection of Policyholders’ Interests, 2024).
- A claim should not be rejected or closed merely for want of documents or delayed intimation. Still intimate early and submit complete documents.
- Complaints: the insurer should resolve a grievance within 14 days.
Before you need it: a short checklist
- Keep the policy schedule, health card and insurer helpline number in your phone.
- Know the network hospitals near you.
- Understand your room-rent limit, co-payment and sub-limits.
- Disclose every pre-existing condition when you buy or renew.
- Keep medical records and bills organised in one folder.
Read our guide on how to choose health insurance.
Frequently asked questions
How quickly must an insurer approve a cashless request?
IRDAI’s 2024 health master circular says the insurer should decide on a cashless authorisation request within 1 hour, and give final authorisation within 3 hours of the hospital’s discharge request.
How long does a reimbursement claim take?
IRDAI’s 2024 circular on protection of policyholders’ interests says non-cashless health claims should be settled within 15 days of submission, subject to complete documents.
Can I get cashless treatment in a non-network hospital?
Usually not. In a non-network hospital you normally pay and then claim reimbursement. Check your policy and ask your insurer before admission.
What are non-payable items?
Items the policy does not cover, such as many consumables and some administrative charges. They are deducted even in a cashless claim, so ask the hospital for the list.
My claim was rejected. What should I do first?
Ask for the written rejection reason with the exact policy clause, then send a written complaint to the insurer’s Grievance Redressal Officer. Escalate to IRDAI’s Bima Bharosa or the Insurance Ombudsman if it is not resolved.
Does a pre-existing disease always lead to rejection?
No. If it was properly disclosed, the claim depends on the waiting period and conditions in your policy. Hiding it is what usually causes disputes.
Need help with your claim?
Binod Kumar Shukla provides claim assistance: documents, coordination with the insurer, follow-up and escalation guidance. The insurer takes the final decision as per the policy terms.
Claim assistanceWhatsApp 9911581705Related guides
Sources: IRDAI Master Circular on Health Insurance Business (Ref. IRDAI/HLT/CIR/PRO/84/5/2024, 29 May 2024); IRDAI Master Circular on Protection of Policyholders’ Interests, 2024 (Ref. IRDAI/PP&GR/CIR/MISC/117/9/2024, 5 September 2024); IRDAI Bima Bharosa (bimabharosa.irdai.gov.in).
This guide is general information for policyholders and is not legal advice. Claim approval, amount and timeline depend on your policy terms, the facts of the loss and the insurer’s assessment; we cannot guarantee any claim outcome. Rules and limits change, so please confirm the current position with your insurer or the regulator. Insurance is the subject matter of solicitation. Binod Kumar Shukla is an IRDAI-certified Insurance Advisor and an agent of LIC of India, National Insurance Company and Niva Bupa, a Chief Life Insurance Advisor (CLIA) and LIC Chairman’s Club member, and an AMFI-registered Mutual Fund Distributor (ARN-50844, EUIN E053991). Claim assistance is provided for documentation, coordination and process guidance; it is not a guarantee of any claim outcome. Reviewed 7 November 2026.