Claim Pitfalls, Complaints and Official Sources
Reimbursement health claim in India: documents, deadlines and how to file
How to file a reimbursement health insurance claim in India, the documents to collect at discharge, typical deadlines, pre and post hospitalisation bills, and claiming from two policies.
For a reimbursement claim, you pay the hospital yourself and then send the insurer or its TPA a claim form with the original or digitally verified bills, discharge summary, investigation reports, prescriptions and payment receipts. Inform the insurer of the admission as soon as possible (many wordings ask within 24–48 hours for emergencies and in advance for planned treatment), and submit the documents within the period in your policy, commonly 15–30 days from discharge. Claims for pre- and post-hospitalisation expenses are filed separately within their own windows. IRDAI's current rules give insurers 15 days to settle claims other than cashless; in practice the clock runs from the date the insurer has all the necessary documents, so submit everything at once.
This guide is part of the overview of health insurance claim rejection reasons.
When you will claim by reimbursement
- The hospital is not in the insurer's network and cashless was not approved.
- Cashless was denied for want of information.
- You are claiming pre- and post-hospitalisation costs (tests and medicines before and after the stay).
- You are claiming the balance from a second policy after the first insurer settled.
Documents to collect before leaving the hospital
| Document | Why it matters |
|---|---|
| Discharge summary (signed, with diagnosis, history, treatment, dates) | The core medical record the insurer reviews |
| Final itemised bill | Shows each charge; needed for non-payable and room-rent checks |
| Payment receipts | Proof you paid |
| Investigation reports (blood tests, imaging, ECG etc.) | Support the diagnosis |
| Prescriptions and pharmacy bills | Medicines claimed |
| Doctor's certificate or notes | Supports medical necessity |
| Implant invoices or stickers | For stents, lenses, joints |
| For accidents: FIR or medico-legal certificate | Required in many wordings |
| Death summary, where applicable | For claims after a death |
Ask for these before discharge; obtaining them later can take weeks. Keep photocopies or scans.
Documents from you
- Duly filled claim form, signed
- Policy number or health card
- KYC (identity proof) and a cancelled cheque or bank details for payment (NEFT)
- For a second policy: the first insurer's settlement letter and attested copies of documents
Worked example: claim with pre- and post-hospitalisation
Illustrative. Policy with 30 days pre-hospitalisation and 60 days post-hospitalisation cover. Admission 10 to 14 March for a surgery; no network hospital.
| Expense | Date | Amount | Claim with |
|---|---|---|---|
| Consultations and tests leading to admission | 20 Feb – 8 Mar | ₹14,500 | Main claim (within 30 days before) |
| Hospital bill | 10–14 Mar | ₹1,85,000 | Main claim |
| Follow-up visits and medicines | 15 Mar – 10 May | ₹11,200 | Post-hospitalisation claim |
| Physiotherapy prescribed by the treating doctor | 20 Mar – 30 Apr | ₹9,000 | Post-hospitalisation, if covered in the wording |
| Medicines bought on 20 May | 20 May | ₹2,000 | Not payable: beyond 60 days |
Main claim: ₹1,99,500. Post-hospitalisation: ₹20,200 (if physiotherapy is covered). The pre-hospitalisation expenses must relate to the same condition for which you were admitted.
Deadlines and settlement timelines
- Intimation: as stated in the wording; inform early even if you are unsure you will claim.
- Submission: as stated in the wording; late submission may be condoned if the delay is explained and genuine. IRDAI expects insurers not to reject genuine claims only for delay.
- Settlement: IRDAI's health insurance FAQs give 15 days for settlement of claims other than cashless. Interest for delay is governed by IRDAI's policyholder protection rules; check the current provision on the IRDAI website.
- Queries: the insurer should raise all its document requirements at once, not piecemeal. If it keeps asking for new documents, record each request.
Claiming from two policies
If you have a group policy and a personal policy, you can choose which to claim from first. File the full claim with the first insurer; it keeps the originals. Then file the balance with the second insurer using the settlement letter and attested copies. Many people claim first from the employer's group cover to protect the personal policy's cumulative bonus. See group vs personal cover.
Common mistakes
- Not informing the insurer in time for a planned admission.
- Leaving without the itemised bill or reports.
- Discharge summary does not mention when a condition was diagnosed, prompting a PED query. Ask the doctor to record history accurately.
- Pharmacy bills without the doctor's prescription.
- Bank details mismatch with the policyholder's name.
For deductions you might see on the settlement, see claim settled for less than the bill. For cashless claims, see cashless claim timelines.
Frequently asked questions
Can I submit scanned documents?
Many insurers accept online submission of scanned documents through their apps or portals, and may ask for originals for higher claims. Follow your insurer's instructions.
Who pays for the delay if the insurer is late?
IRDAI rules require interest on delayed settlement. Mention the date you submitted the last document when you follow up.
Can the insurer ask me for the hospital's internal case papers?
It can ask for documents reasonably needed to assess the claim. If the hospital will not release them to you, ask the insurer to obtain them directly.
Sources and where to check
- IRDAI — master circulars on health insurance and policyholder protection
- Bima Bharosa — complaints about delays
- Council for Insurance Ombudsmen — escalation
