How to File a Health Insurance Claim in India: Cashless & Reimbursement Procedures Explained.

In India, the task of filing a health insurance claim has been made easier and quicker by the Insurance Regulatory and Development Authority of India (IRDAI). Whether you are choosing cashless claims or reimbursement claims, you can find a simple guide below:

Cashless Claims Process

A cashless claim involves treatment without needing to pay upfront at a network hospital. The cashless claim process consists of:

Pre-Authorization notification: Give the insurer notice of proposed hospitalization 48–72 hours in advance. In the case of an emergency, as much notice as possible, no later than 24 hours after you have been admitted.

Approval Time: Insurers must approve or deny a cashless claim within ONE hour of the claim being made.

Discharge: After discharge from the hospital, the insurer must pay the hospital fees within 3 hours of being notified. If the insurer is tardy in processing the request, the insurer must pay for any additional hospital charges.

Reimbursement Claims Process

If you have the treatment performed at a hospital that is not part of the network or pay out of pocket, you can file a reimbursement claim:

Notification: Tell your insurer about hospitalization as described above.

Documentation: After discharge, you have between 7–15 days to submit the following:

Completed claim form

Final bills and discharge summaries for the hospital

All prescriptions and diagnostic reports

Any pharmacy bills

Cancelled cheque to provide bank details

 

IRDAI Health Claim Guidelines

There have recently been important guidelines introduced by the IRDAI to improve the transparency and efficiency of the claim process.

Timely Settlements: Insurers must now complete their claims within 15 days of all documentation being received. Any delays beyond this timeline will incur interest charges to the policyholder.

No Unreasoned Rejection: Claims cannot now be rejected without the approval of a Claims Review Committee to ensure fairness.

Cashless Everywhere: Policyholders may also now benefit from cashless treatment at non-network facilities, subject to the approval of your insurer.