Reimbursement & Cashless Claims Procedure

What is Covered under Health Insurance Claims?

The insurance company will provide coverage if you are diagnosed with any kind of medical condition, injuries, and require medical assistance including surgeries. The insurance company will also cover your stay in the hospital and the price of medicines and other similar items.  

Make sure your condition is not pre-diagnosed before you avail yourself of the health insurance policy, and you don’t seek any kind of cosmetic surgery. Under the current regulations, the waiting period for pre-existing diseases has been reduced by many insurers to a maximum of three years, after which coverage must be provided. In these cases, the insurance company can refuse to provide insurance coverage.

What is Not Covered under Health Insurance Claims?

Given below are the conditions for which the insurance company may refuse to provide coverage. They are:  

1. Pre-existing illnesses  

1. Cosmetic surgeries  

1. Complications related to infertility or pregnancy  

1. Cost incurred for alternate therapies   

1. Complications due to consumption of drugs, alcohol, or smoking  

1. Health supplements  

1. Diagnostic charges unless part of an on-going treatment  

1. Alternative therapies like AYUSH (Ayurveda, Yoga, Unani, Siddha, and Homeopathy) are now covered up to the full sum insured by most insurers, provided the treatment is taken in a government recognized or accredited hospital. 

Eligibility Criteria for Health Insurance Claims

The eligibility criteria to avail a health insurance policy is very simple: 

1. Under the latest IRDAI guidelines, there is no longer a maximum age limit to purchase a new health insurance policy. You can now be diagnosed with a pre-existing illness and apply for insurance, as insurers are now prohibited from refusing policies to individuals with severe conditions like cancer or heart disease.
2. For the claim process, have all your documents in place and inform the insurer about the treatment immediately. 

Documents Required for Health Insurance Claims

The documents you will need to submit during the claim process are given below: 

1. Duly filled claim form 
2. Health Card
3. Consultation papers provided by your doctor
4. Hospital bills including all the receipts stating the payment done by you
5. Diagnosis reports
6. FIR or Medico Legal Certificates if required
7. Payment receipts and invoices provided by the pharmacy during the purchase of medicines and other items
8. Summary of the discharge of the patient 
9. Any other documents as asked for by the insurer 
10. Your health insurance policy documents 

1. KYC documents like your Aadhaar card or PAN card 

1. A cancelled cheque or bank passbook copy for NEFT settlement to ensure the reimbursed amount is credited directly to your account. 

Health Insurance Claim Process

The health insurance claim process is broadly classified as cashless claims and reimbursement claims. It is important to understand the procedure to avoid any delays during emergencies. 

Cashless Claim Process

Step 1: To avail yourself of a cashless claim, you need to get admitted to a network hospital. Under the “Cashless Everywhere” initiative, you can now also request cashless facilities at non-network hospitals by notifying your insurer at least 48 hours before elective surgery or within 48 hours of an emergency.

Step 2: At the hospital, you will have to show your health insurance card for identification. 

Step 3: You will receive the pre-authorisation form from the hospital. 

Step 4: You need to fill out the form and submit it at the hospital’s insurance desk. 

Step 5: Once your form is reviewed, it will be forwarded to the insurer by the hospital. 

Step 6: The insurer will review your application form and documents. The insurer is now required to provide a decision on the pre-authorization request within one hour of receipt to ensure timely medical care.

Step 7: After approval, the insurer authorises the claim as per policy terms. 

Step 8: Your insurer directly settles the approved bill with the hospital. The final discharge authorization must be processed by the insurer within three hours of the hospital sending the final bill.

Reimbursement Claim Process

Step 1: In the reimbursement claim process, you will have to inform your insurer about admission to a non-network hospital. 

Step 2: Once you undergo treatment and settle the hospital bill at discharge, collect all the medical papers, reports, and bills. 

Step 3: Fill out the reimbursement claim form and attach the required documents. A copy of your PAN card and a cancelled cheque for the bank account where you wish to receive the funds must be included.

Step 4: Submit the reimbursement claim form to the insurer. 

Step 5: The insurer will review the claim form and verify the documents. 

Step 6: Once approved, the insurer transfers the claim amount to your bank account. The insurer must settle the claim or provide a reason for rejection within 30 days of receiving all necessary documents to avoid paying interest on the delay.

Cashless Claim Process for Planned Treatment 

Under the initiative “Cashless Everywhere,” you can get this facility at any preferred hospital of your choice by following the specific intimation timelines. 

The claims process for treatment at a cashless network hospital varies according to the type of treatment - Planned or Unplanned. Unplanned medical treatment at a cashless network hospital usually happens in case of an emergency.  

The cashless claims process for planned treatment is as follows:  

1. You must submit the cashless claim form to your insurer by letter or email at least 48 hours  before your scheduled treatment to comply with the latest industry standards for cashless everywhere.

1. Once the insurer receives your cashless claim form, they will notify the hospital. Under the IRDAI Master Circular 2024, the insurer must now decide on this pre-authorisation request within one hour of receipt. 

1. You will then receive a confirmation letter, which remains valid for the duration specified by your insurer, often up to fifteen days depending on the treatment type.

1. Your medical expenses will be paid by the insurance company. The final discharge authorisation must be granted within three hours of the hospital’s request; if the insurer delays beyond this, they are liable to pay any additional costs charged by the hospital. If your claim is rejected, you will receive a notification about the same on your email address and registered mobile number. No claim can be rejected without the approval of the insurer’s Claims Review Committee to ensure a fair decision. 

Disclaimer: Under the latest government regulations effective 22 September 2025, health insurance premiums for individuals are now exempt from GST, which may significantly reduce your overall cost.

How to Claim Reimbursement for Pre- and Post-Hospitalization Expenses 

The majority of health insurance policies include coverage for relevant costs incurred before and after hospital discharge as well as for hospitalisation costs. Under the latest IRDAI Master Circular, insurers are now generally required to provide coverage for pre-hospitalisation expenses for 30 days and post-hospitalisation expenses for 60 days, though many modern plans also extend this to 60 and 90 days respectively.

You may add these costs when filing your claim if your whole request is being reimbursed.  

However, if the hospitalisation was cashless, you might need to submit a second reimbursement application. According to the insurance company's terms and rules, the medical bills for the illness for which the insured was hospitalised must be presented. 

The insurer will reimburse the appropriate pre- and post-hospitalisation costs after verification within a predetermined time frame. That time frame is now strictly regulated, as insurers must settle or reject a reimbursement claim within 30 days of receiving all necessary documents; failure to do so requires the insurer to pay interest at a rate 2% above the bank rate. 

Reasons for Health Insurance Claim Rejections

At times, the health insurance claim gets rejected. Some of the reasons behind claim rejections are given below:  

1. Inaccurate personal details are one of the most common reasons for claim rejection. Any error in personal details, medical history, or policy information can lead to claim rejection.  

1. Not declaring any past illness is another common reason for claiming rejection. However, a policy cannot be contested on the grounds of non-disclosure after it has been active for a continuous period of five years, known as the moratorium period. 

1. Your application will also get rejected if you are raising a claim of diseases or treatments not covered under your insurance policy. Some conditions, procedures, or hospital charges may be excluded under the policy, leading to non-payment.  

1. At times, claims from hospitals that are not legally registered or do not meet insurer standards may not be accepted.  

1. If your policy is inactive or expired at the time of hospitalisation, the insurer will not pay the claim. Under current rules, if you fail to renew on time, you still have a grace period of 30 days to pay the premium and keep the continuity benefits, although coverage is not provided for the days the policy was lapsed. 

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Ways to Avoid Health Insurance Claim Rejections

Given below are some of the ways through which you can avoid getting your health insurance claims rejected:  

1. Make sure your insurance provider is aware of any existing medical conditions you may have. Under the latest IRDAI guidelines, a policy becomes incontestable after five years of continuous coverage, meaning an insurer cannot reject a claim due to non-disclosure after this “moratorium period” has passed. 

1. Do not forget to notify your insurance provider within the required timeframe of any emergency or planned hospitalisation. This notification is now essential for the “Cashless Everywhere” facility, requiring 48-hour notice for planned treatments or notice within 48 hours of an emergency admission. 

1. Before filing a claim, make sure to carefully review the inclusions, exclusions, claim filing procedure, waiting periods, and all other features and benefits of your policy. Insurers under the 2024 Master Circular, are now required to provide a “Customer Information Sheet” (CIS) that summarizes these complex details in simple, easy-to-read language. 

1. Send your insurance provider the required documentation in the original form. Under current digital transformation norms, many insurers now accept scanned copies through their official mobile apps for faster processing, though you should retain the originals for at least three years. 

1. Enter a network hospital and take advantage of the cashless claim services there. Alternatively, you can now use the cashless facility at non-network hospital of your choice, provided the hospital agrees to the insurer’s standard rates and you follow the mandatory intimation process.