How to File a Health Insurance Claim Step by Step
A health insurance claim is the moment your policy is finally tested and it usually goes wrong for reasons that have nothing to do with the illness. Many claim denials and delays trace back to a missed timeline, a wrong document, or a step taken out of order.
This guide walks through both ways to claim, cashless and reimbursement, with a walk-through of the documents, deadlines and hospital coordination that determine how smoothly it goes.
Cashless
Reimbursement
Two Ways to File a Health Insurance Claim
Every health insurance claim runs through one of two routes.
- Cashless: The insurer settles the hospital bill directly. You pay only for items your policy does not cover.
- Reimbursement: You pay the hospital yourself, then claim the amount back from the insurer with your documents.
Cashless | Reimbursement | |
Who pays the hospital | The insurer, directly | You, upfront |
Where it works | Network hospitals and others under Cashless Everywhere* | Any hospital |
Your cash outflow | Only non-covered items | The full bill, recovered later |
Main effort | Pre-authorisation | Document collection |
*Cashless Everywhere is a health insurance feature that allows you to receive medical treatment without paying out-of-pocket, even at hospitals that are not on your insurer’s approved network list.
How to File a Health Insurance Claim: The Steps
Cashless is the smoother route because the paperwork moves between the hospital and the insurer rather than through you.
Planned Hospitalisation
When a procedure is scheduled in advance:
- Choose an Eligible Hospital: Go to a network hospital, or any qualifying hospital under Cashless Everywhere.
- Inform Your Insurer: Notify the insurer ahead of admission. Network hospitals usually require 48 to 72 hours’ prior notice. For a non-network hospital under Cashless Everywhere, the General Insurance Council requires intimation at least 48 hours before admission.
- Submit the Pre-authorisation Request: The hospital insurance desk submits the pre-authorisation form with your doctor’s recommendation.
- Wait for Claim Approval: The insurer must decide on the request within one hour, under IRDAI’s 2024 Master Circular.
- Receive Treatment: Once approved, treatment begins. The insurer and TPA collect the bills and records from the hospital directly.
- Complete Final Settlement at Discharge: At discharge, the final authorisation must be completed within three hours. You pay only for charges not covered under your policy.
Emergency Hospitalisation
In an emergency, the order flips. Treatment comes first, paperwork follows.
- Get the Treatment: Get the patient admitted and treated. Health comes before the claim.
- Inform Your Insurer: Intimate the insurer within 24 to 48 hours of admission. Under Cashless Everywhere, a non-network hospital must be notified within 48 hours.
- Submit the Emergency Pre-authorisation Request: The hospital desk or TPA submits the emergency pre-authorisation request.
- Wait for Claim Approval: The insurer decides on the request within one hour.
- Final Settlement at Discharge: Final discharge authorisation is provided within three hours.
You do not chase documents for cashless.
Under the 2024 Master Circular, insurers and TPAs collect the required documents from the hospital. The policyholder is not asked to run between counters submitting them.
Filing a Reimbursement Claim
Reimbursement applies when you use a non-network hospital, when cashless is not approved in time, or when you simply pay first and claim later.
- Inform the Insurer: Notify your insurer 48 to 72 hours before admission for planned treatment and for emergencies, within 24 to 48 hours of admission.
- Settle the Bill: Pay the hospital at discharge and keep every receipt.
- Collect All Original Documents: Gather all documents, including bills, the discharge summary, prescriptions and reports.
- Complete and submit the Claim Form: Fill out the reimbursement claim form provided by your insurer. Submit within your policy’s window: This varies by insurer, commonly 15 to 30 days from discharge. Check your own policy.
- Answer Any Queries: The insurer may ask for clarification or additional records.
- Receive the Settlement: The insurer must settle within 30 days of receiving all documents, per IRDAI.
Documents You Will Need
Keeping the right paperwork is the single biggest factor in a clean claim. Originals matter for reimbursement.
Identity and Policy
- Policy copy or health card
- Government photo ID
- Filled and signed claim form
Hospital Records
- Admission and discharge summaries
- Doctor’s prescriptions and case sheet
- Treating doctor’s notes
Bills and Receipts
- Itemised hospital bill instead of a summary bill
- Pharmacy bills
- Payment receipts
Diagnostics
- Lab and pathology reports
- Imaging reports and films
Situation-specific
- Medico-Legal Certificate or FIR for accidents
- Implant sticker and invoice, where applicable
- Cancelled cheque or bank details for the reimbursement transfer
The 2024 Master Circular set firm clocks on cashless claims. These are policyholder rights, not optional timelines.
Stage | Timeline |
Cashless pre-authorisation decision | Within 1 hour of the request |
Final discharge authorisation | Within 3 hours of the hospital’s request |
Reimbursement settlement | Within 30 days of all documents |
Settlement beyond the timeline | Interest at 2% above the bank rate on the delayed amount |
Source: IRDAI Master Circular on Health Insurance Business, 29 May 2024.
If discharge drags past three hours? It can happen due to pending approval. If that happens, the extra hospital charges are the insurer's responsibility, paid from its own funds, not yours
Coordinating With the Hospital
The hospital plays an active role in the claim process. A few simple steps can make it smoother.
- Use the Insurance Help Desk: Most hospitals have a desk or TPA counter that raises and tracks pre-authorisation. Start there at admission.
- Note the Submission Time: Ask the desk when the pre-authorisation was sent to the insurer. That timestamp helps you track whether the required timelines have been followed.
- Keep Your Claim Number: It lets you track status through the insurer’s app, portal, or helpline rather than waiting in the dark.
- Check the Room Eligibility Limit: Choosing a room above your eligible limit can trigger proportionate deductions across the whole bill, even when treatment is covered.
Tips to Avoid Delays and Rejections
Most claim issues can be avoided with a few simple steps:
- Intimate Early: Do not wait. Late intimation invites extra queries.
- Disclose Accurately at Purchase: The proposal form plays an important role during claim assessment.
- Keep Originals and Itemised Bills: A lump-sum bill without a breakdown slows verification.
- Follow the Pre-Authorisation Order: Skipping steps to save time usually adds time.
- Read Your Customer Information Sheet: Every policy now carries this one-page summary of cover, exclusions and the claim process.
- Know Your Sub-Limits: Room rent caps, co-payments and disease-wise limits shape the final payout
- Widens Your Options with Cashless Everywhere: Since the General Insurance Council’s January 2024 initiative, you can request cashless treatment at hospitals outside your insurer’s panel, subject to prior intimation and policy terms. Network hospitals still tend to process faster.
Stuck on a claim or a pre-authorisation that won't move? A claim is hard to handle alone when timelines are slipping and the insurer keeps asking for more. Talk to an expert who can read your situation and explain your next step in plain language.
If a claim is denied or delayed, understand what your policy wording says before responding. A careful review of the terms or an independent policy review can often clarify the reason behind the issue.
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Frequently Asked Questions
1. Should I choose a cashless or reimbursement claim?
Cashless is easier on your finances, since the insurer pays the hospital directly and you cover only non-included items. Reimbursement works at any hospital, but it means paying upfront and claiming back. If your hospital supports cashless, it is usually the simpler route.
2. How soon must I inform the insurer about a claim?
For planned hospitalisation, intimate 48 to 72 hours before admission. For emergencies, inform the insurer within 24 to 48 hours of admission. Exact windows vary by policy, so check the terms and intimate as early as you can.
3. Can I get cashless treatment at a hospital that is not in my insurer's network?
Often, yes. Under the General Insurance Council’s Cashless Everywhere initiative from January 2024, cashless can be requested at non-network hospitals that meet basic norms, with prior intimation. Network hospitals still process faster because their systems are already integrated with insurers.
4. How long does the insurer take to settle a reimbursement claim?
Under IRDAI’s 2024 Master Circular, the insurer must settle within 30 days of receiving all required documents. If settlement is delayed beyond the prescribed period, interest is payable at 2% above the bank rate on the delayed amount.
5. What happens if cashless approval is pending and discharge gets delayed?
The final discharge authorisation must come within three hours of the hospital’s request. If the delay runs longer, any additional hospital charges caused by the wait are borne by the insurer, not by you.
6. Do I have to collect documents myself for a cashless claim?
No. The 2024 Master Circular places that duty on the insurer and TPA, who collect the bills and records from the hospital directly. For reimbursement, however, you do need to gather and submit the original documents yourself.
7. Can I claim from two health policies for the same hospitalisation?
Yes. If you hold more than one policy, such as an employer plan and a personal one, you can use them together. One acts as the primary claim, and the other covers the balance, and you have the right to choose which policy to claim from first.
Disclaimer: MyRupia is an independent information and guidance platform. We are not an insurer, agent, or broker, and we do not sell or recommend insurance products. This guide is for educational purposes only. Claim procedures, timelines and document requirements vary by insurer and policy. Always refer to your policy wording and the IRDAI for the rules that apply to your case.
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