Health Insurance Claim Process 2026: Cashless and Reimbursement, Step by Step
Last updated: 27 October 2026
Quick answer: The health insurance claim process has two routes. In a cashless claim, a network hospital sends a pre-authorisation request and IRDAI requires the insurer to decide within one hour and approve discharge within three hours. In a reimbursement claim, you pay the hospital, then submit the claim form, discharge summary, bills and reports to the insurer. Rejections can be escalated to the insurer, Bima Bharosa and the Insurance Ombudsman.
Last updated: 27 October 2026 Quick answer: The health insurance claim process has two routes. In a cashless claim, a network hospital sends a pre-authorisation request and IRDAI requires the insurer to decide within one hour and approve discharge within three hours. In a reimbursement claim, you pay the hospital, then submit the claim form, discharge summary, bills and reports to the insurer. Rejections can be escalated to the insurer, Bima Bharosa and the Insurance Ombudsman. Key takeaways 1 hour: the maximum time for a cashless authorisation decision under IRDAI's 29 May 2024 master circular. 3 hours: for final discharge approval; any extra hospital charge from the delay is borne by the insurer. Documents: insurers and TPAs should collect claim documents from the hospital, not make you chase them. Rejections: need sign-off from a claims review committee and written reasons citing the policy clause. 60 months: after five years of continuous cover, a claim cannot be refused for non-disclosure, except proven fraud. A family in Kharadi spends six hours at a hospital billing counter on discharge day, waiting for the insurer's final approval while the room meter keeps running. Until 2024, that wait was common and often the family paid for it. IRDAI's Master Circular on Health Insurance Business, dated 29 May 2024, changed the rules: the insurer now has three hours, and if it takes longer, the extra cost is its problem, not yours. This guide explains the health insurance claim process as it works in October 2026: how cashless and reimbursement claims differ, the IRDAI timelines you can quote to a hospital desk, the documents that decide whether you get paid, why claims are cut or rejected, and how to escalate. It applies to individual, family floater and most group mediclaim policies. What is a health insurance claim, and what are the two ways to file it? A health insurance claim is your request to the insurer to pay for a hospitalisation or treatment covered by your policy. There are two routes: Cashless claim: you are treated at a hospital in the insurer's or third-party administrator's (TPA) network. The insurer pays the approved amount directly to the hospital; you may still pay the rest, such as co-pay, deductibles and items the policy does not cover. Reimbursement claim: you pay the hospital yourself, usually because it is outside the network or cashless was not approved, and then claim the money back from the insurer. Both routes are judged against the same policy wording: sum insured, room rent limits, sub-limits, co-pay, waiting periods and exclusions. Cashless is a payment method, not a different level of cover. IRDAI has told insurers to work towards 100% cashless settlement, with reimbursement only in exceptional cases. Cashless vs reimbursement health insurance claim comparison What did IRDAI's 2024 master circular change for health claims? The circular (reference IRDAI/HLT/CIR/PRO/84/5/2024) replaced dozens of older instructions with one rulebook. Insurers had to put the systems in place by 31 July 2024. The parts that matter most when you claim: Rule What it means for you Cashless authorisation within 1 hour The insurer must decide on the hospital's request immediately, and in any case within one hour of receiving it. Discharge authorisation within 3 hours Final approval is due within three hours of the hospital's discharge request. If it is late, any extra amount the hospital charges is paid by the insurer from its shareholders' funds. Documents collected by insurer/TPA You should not be asked to collect and submit papers the hospital already has; the insurer or TPA gets them directly. Claims review committee No claim may be rejected without approval from a claims review committee, and the denial letter must cite the specific policy clause. Death during treatment The claim must be processed immediately and the body released from the hospital without delay. Moratorium of 60 months After five years of continuous cover (including ported years), no claim can be contested for non-disclosure or misrepresentation, except established fraud. Choice among multiple policies If you have a group cover and a personal policy, you choose which one pays; the first insurer coordinates the balance with the other. Ombudsman awards An insurer that does not implement an ombudsman award within 30 days must pay ₹5,000 a day to the complainant. Health insurance claim process timelines: cashless authorisation in one hour and discharge in three hours One honest caveat: these are obligations on insurers, not guarantees of speed at every hospital. Delays still happen, especially when the hospital sends an incomplete request. Knowing the rules lets you push back politely and escalate with evidence. How to file a cashless health insurance claim, step by step For a planned admission (a knee replacement, cataract surgery, a scheduled delivery), start the cashless process a few days in advance. Most policies ask for intimation at least 48 to 72 hours before admission; check your policy wording. For an emergency , get admitted first; the hospital's insurance desk will raise the request, and most policies expect intimation within 24 hours. Confirm the hospital is in network. Check the insurer's website or app. Insurers must publish their list of cashless hospitals. Network lists change, so check again before a planned surgery. Carry the health e-card and photo ID. Give them to the TPA or insurance desk. For group cover, carry your employee ID. The hospital submits the pre-authorisation request. It includes the diagnosis, proposed treatment and estimated cost. Ask the desk for the request reference. Insurer decides within one hour. You may get approval of an initial amount, a query, or a denial with reasons. A query is not a rejection; respond quickly. Enhancement if the bill grows. If treatment costs exceed the initial approval, the hospital requests an enhancement. Discharge. The hospital sends the final bill and discharge summary. The insurer must give final authorisation within three hours. Pay the non-payable portion and collect copies of the final bill, discharge summary and the insurer's settlement letter. Cashless health insurance claim process step by step What you will still pay in a cashless claim Non-medical items: many consumables (gloves, masks, admission kits) are excluded unless you bought a consumables add-on. Room rent excess: if you choose a room above your policy's limit, a proportionate share of related charges can be deducted, not just the rent difference. Co-pay or deductible: common in senior citizen plans and super top-ups. Sub-limits: some policies cap specific procedures such as cataract surgery. Read the Customer Information Sheet (CIS) that came with your policy. IRDAI requires every insurer to issue one, summarising cover, exclusions, sub-limits and waiting periods in plain language. It is the fastest way to predict your out-of-pocket share. How to file a reimbursement claim and which documents you need Use reimbursement when the hospital is outside the network, when cashless was denied (for example, the TPA wanted more information than the hospital could provide in time), or for pre- and post-hospitalisation expenses such as tests and medicines before and after the stay. Reimbursement health insurance claim process and documents Documents checklist for a reimbursement claim Document Why it matters Duly signed claim form (Part A by you, Part B by the hospital) Formal claim; Part B carries the hospital's medical details Original discharge summary Diagnosis, treatment and dates; the core document for admissibility Final hospital bill with itemised break-up and payment receipt Shows what was paid and allows item-wise assessment Investigation reports (blood tests, scans) and prescriptions Proves medical necessity of the hospitalisation Pharmacy bills with prescriptions Medicines bought outside the hospital bill Policy copy or e-card, photo ID, PAN Identifies the insured and policy Cancelled cheque or bank details (NEFT form) For the payout FIR or medico-legal certificate (accident cases) Required where the hospital registered a medico-legal case Submission deadlines are set by each policy, typically 15 to 30 days from discharge for the main claim and a separate window for post-hospitalisation bills. Many policies cover pre-hospitalisation expenses for 30 to 60 days and post-hospitalisation for 60 to 180 days; your CIS states the exact numbers. Submit on time, but do not abandon a late claim: insurers can condone delay for genuine reasons, and an outright rejection only for lateness is often challengeable. Keep scanned copies of everything before you courier originals. Most insurers now accept uploads through their app, which creates a timestamped record. Why are health insurance claims rejected or cut? Most disputes are not outright rejections but partial settlements. The common reasons, and what you can do about each: Reason What it usually means Your move Pre-existing disease (PED) waiting period The condition existed before the policy and the waiting period has not ended Check dates; ported years count toward the waiting period Non-disclosure A condition was not declared in the proposal form After 60 months of continuous cover this ground is not available, except fraud Room rent proportionate deduction Room above the limit, so doctor and other charges cut in proportion Choose eligible rooms; ask whether the deduction was applied to excluded items like medicines Not medically necessary / OPD treatment Insurer says the case could have been treated without admission Get the treating doctor's written justification Specific disease waiting period Listed conditions such as cataract or hernia within the waiting period Check the CIS for the list and duration Excluded items or consumables Non-payable list under the policy Ask for an item-wise deduction sheet and challenge errors Honest disclosure at the proposal stage is the single best protection against rejection. If you have a policy that pre-dates a diagnosis, you do not need to report the new condition at renewal; the insurer cannot refuse renewal because you made claims in earlier years. How to escalate a rejected claim: insurer, Bima Bharosa, ombudsman If a claim is denied or short-paid, follow this ladder. Keep every letter, email and reference number. Health insurance claim rejection escalation: grievance, Bima Bharosa, ombudsman Ask for the reasons in writing. IRDAI requires a denial to cite the specific policy clause. Ask for the deduction sheet on partial settlements. Complain to the insurer's grievance officer. Every insurer has a grievance redressal officer; details are on the policy and website. Write clearly: policy number, claim number, amount disputed, why you disagree, documents attached. Use Bima Bharosa. IRDAI's Bima Bharosa portal lets you register a complaint against an insurer and track it. Use it if the insurer does not respond or resolve the issue. Approach the Insurance Ombudsman. Under the Insurance Ombudsman Rules, 2017, you can go to the ombudsman after the insurer rejects your complaint or fails to reply within 30 days, and within one year of that. The process is free and needs no lawyer, and you file with the ombudsman office that covers your area. If an award is not honoured within 30 days, the insurer owes ₹5,000 a day. Consumer commission. For larger or complex disputes, the Consumer Protection Act, 2019 route remains open. For a wider view of complaint routes across SEBI, RBI and IRDAI, see our guide on how to complain through SCORES, ODR, the RBI Ombudsman and Bima Bharosa (/insights/how-to-complain-sebi-scores-odr-ombudsman) . Cashless vs reimbursement: which should you choose? Choose cashless whenever a suitable network hospital is available. It protects your cash flow, and the one-hour and three-hour rules apply. Reimbursement makes sense when the best hospital for the condition is outside the network, or in an emergency where the nearest hospital is not empanelled. In that case, treatment comes first; paperwork can follow. Some steps make either route smoother: Keep a claim file at home: policy copies, e-cards, CIS, TPA helpline numbers and a list of each family member's declared conditions. Know your group cover and personal cover. Employees often have both. You can choose which pays first; use group cover first and keep your personal policy's no-claim bonus intact where the group sum insured is enough. Our guide on gaps in group health cover (/insights/health-insurance-for-corporate-employees-pune) explains why the personal policy still matters. Layer cover sensibly. A super top-up plan (/insights/super-top-up-health-insurance) pays once your claims cross the deductible; keep both insurers informed for large claims. Parents' policies need extra care. Co-pay and sub-limits are common; see health insurance for parents and senior citizens (/insights/health-insurance-for-parents-senior-citizens) . If your current insurer's service has been poor, you can switch without losing waiting-period credit. Read our guide to health insurance portability rules (/insights/health-insurance-portability-rules) before your next renewal, and check how insurers compare using the guide to claim settlement ratios (/insights/claim-settlement-ratio-explained) . A worked example: what a ₹3.2 lakh bill actually costs you Consider a 52-year-old in Pune admitted for five days with a ₹5 lakh family floater, room rent limit of 1% of sum insured (₹5,000 a day), and no co-pay. She chooses a ₹7,000-a-day room. The final bill is ₹3,20,000, including ₹35,000 of room rent and ₹12,000 of non-payable consumables. Item Amount Total bill ₹3,20,000 Less non-payable consumables ₹12,000 Room rent excess (₹2,000 × 5 days) ₹10,000 Proportionate deduction on associated charges (illustrative, 2/7 of ₹1,60,000) about ₹45,700 Approximate amount paid by insurer about ₹2,52,300 Out of pocket about ₹67,700 The proportionate deduction, not the room rent itself, is the expensive surprise. Had she chosen an eligible room, her out-of-pocket cost would have been close to the ₹12,000 of consumables. Exact treatment of associated charges differs across policies, so treat this as illustrative and check your wording. Related reading Porting your health insurance: rules and pitfalls (/insights/health-insurance-portability-rules) Super top-up health plans (/insights/super-top-up-health-insurance) Health insurance for parents and senior citizens (/insights/health-insurance-for-parents-senior-citizens) Section 80D (now section 126) deduction (/insights/section-80d-health-insurance-deduction) Insurance planning in India (/insights/insurance-planning-guide-india) Five policy gaps that can shrink your health insurance claim Many claim shortfalls come from policy terms the buyer never checked: Room rent cap: often 1% of the sum insured per day or a flat amount such as ₹5,000. If you choose a ₹10,000 room on a ₹5,000 cap, the insurer may pay room-linked charges such as doctor fees only in the same 50% proportion. IRDAI's 2024 master circular bars this proportionate cut on pharmacy, consumables, implants, diagnostics and ICU charges. Co-pay: a 20% co-pay on a ₹4 lakh claim leaves you paying ₹80,000. It is common in senior citizen policies and some city-linked plans. Disease-wise sub-limits: for example, cataract capped at ₹40,000 per eye on a ₹5 lakh policy. Non-payable items: gloves, masks and other listed items can still be 5–10% of a bill unless you have a consumables cover. Waiting periods: pre-existing diseases and specified illnesses are covered only after the waiting period, now capped at 3 years for pre-existing diseases. Deductions usually apply in sequence (room-rent proportion, then sub-limits, then co-pay), so a ₹4 lakh claim can settle well below ₹3 lakh. Also note a proposal from the General Insurance Council for a mandatory 10% co-pay on retail health policies from 1 January 2027. It needs IRDAI approval and is not yet a rule. How many claims were settled within three months? IRDAI data for FY 2024-25 shows the share of claims each insurer settled within three months: Insurer type Insurers Settled within 3 months Standalone health insurers Aditya Birla Health, Galaxy, Narayana Health, Niva Bupa 100% Private general insurers Acko 99.98%, Reliance 99.32%, HDFC ERGO 98.85%, ICICI Lombard 98.45% 98–100% Public sector insurers United India 95.26%, National 91.79%, New India 91.75%, Oriental 90.17% 90–95% Speed is only one factor. Also look at the claim settlement ratio, the share of claims paid in full, network hospitals in your city and customer complaint data before you buy. Frequently Asked Questions How long does a cashless claim approval take in 2026? Under IRDAI's Master Circular on Health Insurance Business of 29 May 2024, insurers must decide a cashless authorisation request immediately and within one hour of receiving it. Final discharge approval is due within three hours of the hospital's request. Delays usually arise when the hospital's request is incomplete, so ask the insurance desk to confirm everything was sent. What happens if discharge approval takes more than three hours? If the insurer takes longer than three hours to grant final authorisation after the hospital's discharge request, any additional amount the hospital charges for the delay must be borne by the insurer from its shareholders' funds. You should not be charged for the extra time. Note the time the hospital sent the request in case you need to complain. Can I get cashless treatment at a non-network hospital? Generally no. Cashless works at hospitals empanelled with your insurer or TPA. At a non-network hospital, you pay the bill and file a reimbursement claim. Some insurers have extended cashless access more widely, so call the insurer's helpline before admission to check, but plan for reimbursement as the default. What documents are needed for a reimbursement health insurance claim? The claim form, original discharge summary, itemised final bill with payment receipt, investigation reports, prescriptions and pharmacy bills, policy copy or e-card, photo ID, PAN and bank details. Accident cases also need an FIR or medico-legal certificate if one was registered. Submit within your policy's deadline, often 15 to 30 days from discharge. Can an insurer reject a claim for an undisclosed illness after many years? Not after the moratorium. Once you have 60 months of continuous cover, including years carried over through portability, the insurer cannot contest a claim for non-disclosure or misrepresentation, except where fraud is established. Before 60 months, non-disclosure of a material condition can be grounds for rejection, so declare honestly. How do I complain if my health insurance claim is rejected? Ask for written reasons, then complain to the insurer's grievance officer. If the issue is not resolved, register it on IRDAI's Bima Bharosa portal. If the insurer rejects your complaint or does not reply within 30 days, approach the Insurance Ombudsman within one year. The ombudsman process is free and does not need a lawyer. If I have both a group policy and my own policy, which one should I claim from? IRDAI lets you choose. Many people claim from the employer's group policy first to protect the no-claim bonus on their personal policy. If the bill exceeds the first policy's limit, the balance can be claimed from the second; the first insurer coordinates. Your personal policy remains essential because group cover ends when you leave the job. Sources: IRDAI Master Circular on Health Insurance (reference and text) (https://www.caclubindia.com/notice_circulars/master-circular-on-health-insurance-business-11292.asp) ; Deloitte tax alert on IRDAI health master circular (https://www2.deloitte.com/content/dam/Deloitte/in/Documents/tax/in-tax-gbt-insurance-regulator-releases-new-guidelines-noexp.pdf) ; The Week, 30 May 2024 (https://www.theweek.in/news/india/2024/05/30/irdai-issues-new-master-circular-to-make-health-insurance-claims-process-more-seamless.amp.html) ; Outlook Money (https://www.outlookmoney.com/personal-finance/irdai-master-circular-on-health-insurance-business) ; News Arena India (https://www.newsarenaindia.com/economy/irdai-mandates-cashless-health-claims-by-august-1/13931) . Worked examples are Money n Wealth calculations. Facing a claim cut or planning a hospital admission? A quick review of your policy wording before admission can save tens of thousands in deductions. Talk to Money n Wealth for an insurance review (/contact) . This article is for general educational purposes only and does not constitute financial advice. Figures and examples are illustrative. Please consult a qualified financial adviser for guidance specific to your situation. Money n Wealth (Predics Fintech Services Pvt Ltd) is an AMFI-registered Mutual Fund Distributor (ARN-121995) and APMI-registered PMS Distributor (APRN07444); it is not a SEBI-registered investment adviser and may earn distribution commission on investments made through it. Insurance is the subject matter of solicitation.
Frequently Asked Questions
How long does a cashless claim approval take in 2026?
Under IRDAI's Master Circular on Health Insurance Business of 29 May 2024, insurers must decide a cashless authorisation request immediately and within one hour of receiving it. Final discharge approval is due within three hours of the hospital's request. Delays usually arise when the hospital's request is incomplete, so ask the insurance desk to confirm everything was sent.
What happens if discharge approval takes more than three hours?
If the insurer takes longer than three hours to grant final authorisation after the hospital's discharge request, any additional amount the hospital charges for the delay must be borne by the insurer from its shareholders' funds. You should not be charged for the extra time. Note the time the hospital sent the request in case you need to complain.
Can I get cashless treatment at a non-network hospital?
Generally no. Cashless works at hospitals empanelled with your insurer or TPA. At a non-network hospital, you pay the bill and file a reimbursement claim. Some insurers have extended cashless access more widely, so call the insurer's helpline before admission to check, but plan for reimbursement as the default.
What documents are needed for a reimbursement health insurance claim?
The claim form, original discharge summary, itemised final bill with payment receipt, investigation reports, prescriptions and pharmacy bills, policy copy or e-card, photo ID, PAN and bank details. Accident cases also need an FIR or medico-legal certificate if one was registered. Submit within your policy's deadline, often 15 to 30 days from discharge.
Can an insurer reject a claim for an undisclosed illness after many years?
Not after the moratorium. Once you have 60 months of continuous cover, including years carried over through portability, the insurer cannot contest a claim for non-disclosure or misrepresentation, except where fraud is established. Before 60 months, non-disclosure of a material condition can be grounds for rejection, so declare honestly.
How do I complain if my health insurance claim is rejected?
Ask for written reasons, then complain to the insurer's grievance officer. If the issue is not resolved, register it on IRDAI's Bima Bharosa portal. If the insurer rejects your complaint or does not reply within 30 days, approach the Insurance Ombudsman within one year. The ombudsman process is free and does not need a lawyer.
If I have both a group policy and my own policy, which one should I claim from?
IRDAI lets you choose. Many people claim from the employer's group policy first to protect the no-claim bonus on their personal policy. If the bill exceeds the first policy's limit, the balance can be claimed from the second; the first insurer coordinates. Your personal policy remains essential because group cover ends when you leave the job.
Facing a claim cut or planning a hospital admission?
A quick review of your policy wording before admission can save tens of thousands in deductions. Talk to Money n Wealth for an insurance review .
