Understanding how claims work before you need to file one is the difference between a smooth experience and a nightmare. There are two types of claims: cashless and reimbursement.
Type 1: Cashless Claims (the preferred route)
This only works at hospitals in your insurer's network. Call the number on your policy card to find network hospitals near you.
Step-by-step: Cashless claim
- 1. Go to a network hospital — With your health card and photo ID.
- 2. Inform the insurance desk — Every large hospital has one. Show your policy card.
- 3. Hospital sends pre-authorisation request — To your insurer's TPA (Third Party Administrator).
- 4. TPA approves (usually 2–4 hours) — They approve a certain amount. Sometimes they ask for more documents.
- 5. Treatment proceeds — The hospital treats you without payment upfront.
- 6. Discharge — Insurer pays the hospital directly. You pay only deductibles, co-payments, or amounts exceeding the sum insured.
Type 2: Reimbursement Claims
Used when you go to a non-network hospital, or when cashless is denied.
Step-by-step: Reimbursement claim
- 1. Get hospitalised and pay the bill
- 2. Collect ALL documents — Discharge summary, all bills (itemised), investigation reports, prescription slips, pharmacy bills, doctor's notes
- 3. Intimate the insurer within 24–48 hours of admission (most policies require this)
- 4. Submit claim within 15–30 days of discharge (check your policy)
- 5. Insurer reviews — They may ask for additional documents (this is normal)
- 6. Settlement — Amount credited to your bank account, usually within 30 days of complete documentation
What is a TPA?
A Third Party Administrator (TPA) is a company that manages claims on behalf of the insurer. They verify documents, approve cashless requests, and process reimbursements. Some insurers handle claims in-house without a TPA — this is often faster.
Common reasons claims get delayed or rejected
- Missing documents — Always collect the full discharge summary and itemised bill
- Late intimation — You must inform the insurer within 24–48 hours of admission
- Treatment during waiting period — Pre-existing or named ailment treated before waiting period ends
- Non-disclosure — If you didn't disclose a pre-existing condition at time of buying
- Room rent upgrade — If you took a higher-category room than your policy allows, the insurer applies a proportional deduction on the entire bill
💡 Pro tip: Always intimate first, then arrange documents
Calling your insurer within 24 hours of admission is the single most important step. Missing this alone can result in claim rejection even if the hospitalization is completely covered.
If your claim is rejected
Don't accept the first rejection. You have multiple escalation options — internal grievance, IRDAI IGMS portal, and the Insurance Ombudsman (free, no lawyer needed). See our step-by-step guide to dealing with rejected claims.
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