The IRDAI (Insurance Regulatory and Development Authority of India) has mandated strict, time-bound rules for processing cashless health insurance claims, effective from July 31, 2024. These rules come under the IRDAI Master Circular on Health Insurance Business, 2024.

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1. Cashless Claim Time Limits (Mandatory)

A. Pre-authorisation: within 1 hour

• Insurers must provide cashless claim pre-authorisation within one hour of receiving the hospital’s request.

• The rule is applicable for all insured persons seeking cashless treatment.

• Insurers were required to update their systems to enable this by July 31, 2024.

B. Final Authorisation: within 3 hours

• After the hospital sends the discharge authorisation request, the insurer must issue final approval within three hours.

• Patients must not be made to wait at the hospital for discharge due to insurer delays.

C. If Insurer Delays

• Any additional charges by the hospital due to delays beyond 3 hours must be paid by the insurer, not the policyholder.

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2. Rules in Case of Death of the Policyholder

If the insured person dies during treatment:

The insurer must:

1. Immediately process the claim request

2. Ensure the hospital releases the body without delay

This prevents families from facing administrative hurdles during a sensitive time.

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3. Latest Cashless Authorisation Performance Data (Aug 1, 2024 – May 31, 2025)

Shared by the Finance Minister in Lok Sabha on December 1, 2025

Pre-authorisation

• 86.88% cashless cases were pre-authorised within 1 hour.

Final Authorisation

• 96.69% cashless claim requests received final approval within 3 hours.

This indicates high compliance but still room for improvement, especially at the pre-authorisation stage.

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4. Complaint Handling: Bima Bharosa Platform

IRDAI has integrated its Bima Bharosa consumer grievance portal with insurers’ Complaint Management Systems (CMS).

Key Points:

• Complaints filed in Bima Bharosa instantly reflect in insurers' CMS.

• Complaints filed in insurers’ CMS instantly reflect in Bima Bharosa.

Complaint Resolution Time

• Insurers must resolve complaints within 14 days.

Complaint Statistics

Financial Year 2024–25

• Total complaints: 2,57,790

• Not resolved within 14 days: 4,811

FY 2025–26 (up to Sept 30, 2025)

• Total complaints: 1,36,554

• Unresolved within the time limit: 532

This shows strong improvement in timely complaint resolution.

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5. Escalation to Insurance Ombudsman

• Bima Bharosa is NOT integrated with the Insurance Ombudsman system.

• Complaints are not automatically escalated if the insurer delays resolution.

How a policyholder can escalate:

• File a complaint with the Insurance Ombudsman if:

  • They are not satisfied with the insurer’s reply.

  • The insurer failed to resolve the complaint within 14 days.

Filing modes:

• Physical submission

• Electronic mode (online)

Ombudsman Statistics

• In FY 2024–25, 53,102 complaints were filed before the Insurance Ombudsman.

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6. Summary of Key Changes & Impact

? Faster hospital processes (1-hour & 3-hour rules)

? Reduced discharge delays

? Financial protection for policyholders during insurer delay

? High compliance by insurers (86–96% timely approvals)

? Better complaint transparency through integrated systems

? Clear escalation path to Ombudsman