Health Insurance Claim Process — Step-by-Step Guide (Cashless + Reimbursement)

Filing a health insurance claim in India is one of those tasks no one prepares for until it is happening — usually at the worst possible moment, in a hospital lobby, with a frightened family member nearby. This guide walks through both routes — cashless and reimbursement — with the documents, timelines, and gotchas that determine whether your claim is approved in 7 days or fights its way through the IRDAI grievance system for six months.

The Two Claim Routes

Feature	Cashless	Reimbursement
Hospital type	Network hospital only	Any hospital
Out-of-pocket payment	Only non-payable items	Full bill, claimed back later
Pre-authorisation	Required before/at admission	Not required
Settlement timeline	Same day at discharge	15-30 days post-submission
Documentation burden	Hospital + TPA do most of it	You do everything

Cashless Claim — Step-by-Step

Step 1: Confirm the hospital is in your network

Check your insurer's app or call the toll-free number before admission. Insurers can and do delist hospitals with little notice — never assume last year's network list is still current.

Step 2: Submit the pre-authorisation form

The hospital's TPA desk fills out the pre-auth form with the proposed treatment, estimated cost, and supporting medical documents. This is then sent to your insurer's claims team.

Step 3: Wait for approval (usually 2-6 hours for planned, 1-2 hours for emergency)

The insurer issues an Authorisation Letter (AL) with an approved amount. You sign the consent form and treatment begins.

Step 4: Discharge and final settlement

The hospital sends a final bill with discharge summary to the insurer. The insurer settles directly with the hospital. You only pay non-payable items (consumables in older policies, dietary charges, attendant food, etc.).

Common cashless rejection triggers

• Treatment falls under a waiting period (PED, specific disease, maternity)
• Procedure is on the policy's exclusion list
• Hospital is not on the cashless network
• Pre-existing condition not disclosed at policy purchase
• ICU room rent breach in plans with strict capping

Reimbursement Claim — Step-by-Step

Step 1: Notify the insurer within 24-48 hours of admission

Even if you cannot do cashless, the policy still requires intimation. Most insurers accept WhatsApp, app, email, or phone intimation. Failure to intimate within the policy-stated window is itself a rejection ground.

Step 2: Pay the hospital and collect every original document

Reimbursement is a paper-heavy process. Walk out with everything in original.

Step 3: Submit the claim form within 30 days of discharge

Most insurers give 30 days from discharge to file. Some allow 60. Late submissions are rejected unless you have a written escalation reason.

Step 4: TPA processes and settles within 15-30 days

You will get a query if anything is missing — respond fast. Each query reset can add 7-10 days.

The 15-Item Document Checklist

1. Filled and signed claim form (Part A by insured, Part B by hospital)
2. Original discharge summary
3. Original final hospital bill (itemised)
4. Original payment receipts
5. All diagnostic test reports (X-ray, MRI, CT, blood, biopsy)
6. All pharmacy bills with prescription copies
7. Original consultation papers, prescriptions, admission notes
8. Operation theatre notes (if surgery performed)
9. Implant invoice and sticker (for stents, lenses, joints)
10. Anaesthesia records (for surgery cases)
11. FIR / MLC report (for accident cases)
12. KYC documents — PAN, Aadhaar, cancelled cheque
13. Insured's photo ID
14. Pre and post-hospitalisation medical records (if claiming those expenses too)
15. Death certificate and post-mortem report (in case of mortality claims)

The Role of the TPA

A Third-Party Administrator sits between you and the insurer for claims processing. The big TPAs in India are MDIndia, Health India, FHPL, Vidal, Paramount, and Medi Assist. Some insurers — HDFC ERGO, ICICI Lombard, Niva Bupa, Care — do in-house claims, which is generally faster because there is no TPA-insurer hand-off. When choosing a plan, check whether claims are in-house or TPA-routed; the difference can be 5-10 days at settlement.

Top Reasons Health Insurance Claims Are Rejected

1. Non-disclosure of pre-existing disease — Single biggest cause. If you had hypertension and did not disclose it at policy purchase, any cardiac claim is at risk.
2. Waiting period not served — PED waiting (3 yrs), specific disease waiting (1-2 yrs), maternity (24-36 months).
3. Treatment in exclusion list — Cosmetic surgery, IVF (in older plans), bariatric surgery without medical necessity.
4. Hospital not qualifying as a "hospital" — IRDAI requires minimum bed count, qualified nursing 24x7. Some small clinics fail this test.
5. Documentation mismatch — Discharge summary says one diagnosis, claim form says another.
6. Late intimation or late submission — Procedural and avoidable.
7. Sub-limit breach — Cataract sub-limit is ₹40,000; you got billed ₹65,000; the extra is yours to pay.

If Your Claim Is Rejected — IRDAI Grievance Path

Step 1: File a written representation with the insurer's grievance officer. They have 15 days to respond. Step 2: If unsatisfied, escalate to the IRDAI Bima Bharosa portal. Step 3: If still unresolved after 30 days, file with the Insurance Ombudsman in your zone. The ombudsman can award up to ₹50 lakh and is binding on the insurer. The process is free and does not require a lawyer. Most claim disputes get resolved at step 1 or 2.

Settlement Timeline — What IRDAI Mandates

Stage	Maximum Time
Cashless pre-auth response	1 hour (emergency), 6 hours (planned)
Cashless final approval at discharge	3 hours
Reimbursement settlement after complete documentation	30 days
Investigation cases	45 days

If your insurer breaches these timelines, IRDAI mandates payment of 2% above the bank rate as interest from the date the claim should have been paid.

Practical Tips That Speed Up Settlement

• Always do cashless when possible — it cuts paperwork by 80%.
• Keep your insurer's app installed and policy number screenshot saved.
• At admission, ask the TPA desk for the pre-auth tracking number — follow up if no response in 4 hours.
• For reimbursement, submit a scanned soft copy via app first, then courier originals.
• Respond to insurer queries within 48 hours — every delayed query adds a week.
• Keep a folder (physical and digital) of all medical records — even routine OPD visits — so PED disclosures can be backed up.

If you are still researching plans rather than filing a claim, browse plans by claim performance on the OnePaisa insurance hub.

Key Takeaway

Cashless is fast and clean — use it whenever you are within a network hospital. For reimbursement, the success rate is driven by three things: full PED disclosure at policy purchase, timely intimation within 24-48 hours, and complete documentation at first submission. If anything goes sideways, the IRDAI Bima Bharosa portal and the Insurance Ombudsman are your free, binding escalation paths — and they work. The insurers that consistently settle in under 10 days in 2026 are HDFC ERGO, ICICI Lombard, Niva Bupa, and Care, mostly because they handle claims in-house instead of routing through a TPA.

FAQs

How quickly does a cashless claim get approved at the hospital?

Pre-authorisation typically takes 2-6 hours for planned admissions and 1-2 hours for emergencies. Final settlement at discharge takes another 2-3 hours. Major insurers with in-house claims teams are at the faster end of this range.

What if my hospital says cashless is not available even though it is in the network?

Get this in writing or as a screenshot, then call your insurer's 24x7 helpline. Most cases are resolved in under an hour. If unresolved, pay the bill and file for reimbursement; collect every document.

Can the insurer reject a claim after pre-authorisation was approved?

Yes, but only if new information emerges that materially changes the case — usually a pre-existing condition surfacing in the discharge summary that was not disclosed earlier. Approved pre-auth amounts can also be reduced based on actual final billing.

Are pre and post-hospitalisation expenses covered?

Yes — typically 30-60 days pre-hospitalisation and 60-180 days post-hospitalisation, depending on the plan. Submit them as a separate reimbursement claim with prescription proof.

Does Ayurveda or homeopathy treatment qualify?

Ayurveda treatment in a government or NABH-accredited AYUSH hospital is covered by most modern policies up to the full sum insured. Homeopathy and naturopathy are typically excluded.