Claim Pitfalls, Complaints and Official Sources
Cashless health insurance claims in India: process and IRDAI timelines (1 hour, 3 hours)
Step by step through a cashless health claim in India, from pre-authorisation to discharge, the IRDAI one-hour and three-hour timelines, what to do when cashless is denied.
In a cashless claim, the hospital sends a pre-authorisation request to your insurer or its TPA, the insurer approves an amount, and at discharge it settles the bill directly with the hospital; you pay only non-payable items, co-pay and any amount above your limits. Under IRDAI's Master Circular on Health Insurance Products of 29 May 2024, insurers must decide on a cashless authorisation request within one hour of receiving it, and on the final discharge authorisation within three hours of the hospital's request. If the discharge approval is delayed beyond three hours, any extra amount the hospital charges for the delay is to be borne by the insurer, not you. You do not have to collect and submit documents for a cashless claim; the insurer or TPA is expected to obtain them from the hospital.
This guide is part of the overview of health insurance claim rejection reasons.
Step by step
| Stage | What happens | Your action |
|---|---|---|
| Before a planned admission | Hospital's insurance (TPA) desk sends pre-authorisation | Give your health card, policy number, ID; inform insurer if the wording asks for advance notice |
| Emergency admission | Hospital sends request after admission | Family informs insurer or TPA as soon as possible |
| Initial authorisation | Insurer approves an amount or asks for details | Decision due within 1 hour of a complete request |
| During the stay | Hospital sends enhancement requests if the bill grows | Keep room within your limit if you have a cap |
| Discharge | Hospital sends final bill and discharge summary | Decision due within 3 hours of the hospital's request |
| Settlement | Insurer pays the hospital; you pay the balance | Check the final authorisation letter; keep copies |
Network and non-network hospitals
Cashless is available at the insurer's network hospitals. IRDAI has pushed insurers to widen cashless access, and industry initiatives since 2024 have aimed to allow cashless treatment at non-network hospitals too where the hospital accepts the insurer's terms, usually with advance notice for planned admissions. It is worth asking the insurer whether a non-network hospital can be approved for cashless, especially for a planned admission. If not, you pay and claim reimbursement; see reimbursement claim documents.
Worked example: what you pay at a cashless discharge
Illustrative. Policy: ₹5 lakh, 10% co-pay, no room-rent cap. Final bill ₹2,48,000, of which non-payable items ₹8,000.
| Item | Amount |
|---|---|
| Final bill | ₹2,48,000 |
| Less non-payable items (you pay) | ₹8,000 |
| Admissible amount | ₹2,40,000 |
| Co-pay 10% (you pay) | ₹24,000 |
| Insurer pays hospital | ₹2,16,000 |
| You pay at discharge | ₹32,000 |
Ask the hospital's TPA desk for the authorisation letter, which lists the approved amount and the deductions. The co-pay calculator works out the co-pay part.
When cashless is denied or partly approved
A cashless denial is not a claim rejection. Common reasons at this stage:
- incomplete information from the hospital (no provisional diagnosis, no doctor's notes);
- condition apparently within a waiting period;
- query on pre-existing disease or disclosure;
- room category above the policy limit;
- treatment needing more medical detail.
What to do:
- Ask the hospital desk for the insurer's query and help them answer it with the doctor's notes.
- Ask the insurer or TPA helpline for the reason in writing.
- If cashless is still denied, pay the hospital and file a reimbursement claim with full documents within the time in your policy. The claim is then assessed on all the papers.
- If you believe the denial was wrong, complain to the grievance officer; see complaints and the Ombudsman.
Delays at discharge
The three-hour rule is counted from the hospital's discharge request to the insurer. In practice, delays often come from the hospital preparing the final bill and summary. Ask the hospital in the morning when the discharge request was sent, and ask the TPA helpline for the time it was received. Note these times in case additional charges appear.
Practical tips
- Carry a soft copy of the policy and health card.
- For planned surgery, request pre-authorisation several days in advance.
- Confirm the room category your policy allows before you are shifted to a room. See room-rent limits.
- Ask for an itemised final bill and the final authorisation letter at discharge.
- Check the settlement letter later; challenge any wrong deduction. See claim settled for less than the bill.
Frequently asked questions
Does the one-hour rule apply at night?
The master circular asks insurers to decide immediately and within one hour of a request; there is no daytime exception in the timeline as communicated. In practice, call the helpline if a decision is delayed and record the times.
Can the hospital ask me for a deposit?
Many hospitals take a deposit until the cashless approval arrives, and refund it after settlement. Ask for a receipt.
Do I need to sign anything at discharge?
You will usually sign the final bill and a claim form. Read the amounts before signing.
Sources and where to check
- IRDAI — Master Circular on Health Insurance Products (29 May 2024)
- Bima Bharosa — complaints about cashless delays
- Council for Insurance Ombudsmen — escalation
