Last updated: October 2026 Β· 3 min read
Knowing the claim process before an emergency makes a stressful time easier. Health insurance claims are either cashless, where the insurer pays the hospital directly, or reimbursement, where you pay and claim later.
Cashless claim: step by step
- Choose a network hospital of your insurer or its TPA (third-party administrator).
- Show your health card and ID at the insurance desk.
- The hospital sends a pre-authorisation request with diagnosis and estimate.
- For planned treatment, apply a few days in advance; for emergencies, within 24 hours of admission.
- The insurer approves an initial amount and the final bill at discharge.
- You pay only non-payable items, co-payment or amounts above limits.
IRDAI’s 2024 master circular asks insurers to decide cashless requests within 1 hour and final discharge authorisation within 3 hours.
Reimbursement claim: step by step
- Inform the insurer about hospitalisation as soon as possible.
- Pay the hospital and collect all original documents.
- Submit the claim form with documents within the policy deadline (often 15-30 days of discharge).
- The insurer verifies and pays to your bank account.
Documents usually required
- Claim form signed by the insured.
- Discharge summary.
- Final hospital bill with break-up and payment receipts.
- Doctor’s prescriptions and investigation reports.
- Pharmacy bills.
- Health card, ID proof and cancelled cheque.
- FIR or MLC copy for accident cases.
Common reasons claims are rejected
- Non-disclosure of pre-existing illness.
- Treatment during a waiting period.
- Excluded treatments or cosmetic procedures.
- Hospitalisation not medically necessary.
- Missing documents or late intimation.
- Room rent above the limit leading to proportionate deduction.
If your claim is unfairly rejected
- Ask the insurer for the reason in writing.
- Complain to the insurer’s grievance officer.
- If unresolved in 30 days, use IRDAI’s Bima Bharosa portal.
- Approach the Insurance Ombudsman for free resolution.
Frequently asked questions
How long does a reimbursement claim take?
IRDAI requires insurers to settle claims within 30 days of receiving all documents (longer if investigation is needed).
Can I claim from two health policies?
Yes. You can claim from one policy first and the balance from another by submitting attested copies.
Is OPD covered?
Only if your policy has OPD cover; standard policies focus on hospitalisation.
Keep exploring
- Health insurance basics
- Ayushman Bharat PM-JAY
- Emergency fund guide
- More Insurance articles on Tiwaripedia
This article is for general information, not financial, tax or legal advice. Rates, limits and rules change; always confirm on the official website or with a qualified advisor before you act. Spotted something that needs updating? Let us know.
