Chapter 8 of 12
Health Insurance Claim Process
Cashless vs reimbursement — step by step process.
Priya was admitted to a network hospital in Hyderabad for an appendectomy. She was
terrified — not just about the surgery, but about the financial paperwork. Her husband
had heard horror stories of claims being rejected months after discharge. But Priya was
prepared: she knew exactly what to do, whom to call, and what documents to keep. Her
₹3.8 lakh bill was settled entirely by the insurer through cashless processing — she
paid only ₹2,500 for some non-covered medicines. Knowing the claims process turns a
stressful medical emergency into a manageable financial transaction.
Two Types of Health Insurance Claims
Step-by-Step: Cashless Claim Process
3–5 days before hospitalisation: Contact the insurance desk at the network hospital. Submit your health insurance card and policy number.
Hospital sends pre-auth request to the TPA/insurer with estimated cost, diagnosis, and treatment plan.
Within 2–4 hours (planned) or 1–2 hours (emergency): Insurer/TPA reviews and sends an initial approval (guarantee of payment letter) to the hospital.
- Hospital provides treatment. You sign the admission form and cashless consent.
Keep all prescriptions, test reports, and discharge summary. These documents may be needed even in cashless claims for verification.
If treatment requiring additional coverage is needed, hospital sends a fresh enhancement request. This can take 1–2 hours to approve.
- Hospital generates final bill and sends to TPA for final approval.
- TPA reviews and sends final approval amount (may exclude non-covered items likeregistration fees, service charges, non-medical consumables).
- You pay only the non-covered amount (Priya paid ₹2,500 for certain medicinesand registration charges).
- Collect original discharge summary, prescriptions, and all reports for your records.
Total timeline for Priya: Pre-auth approved in 3 hours, discharged on day 3, final bill settled same day. Zero major out-of-pocket expense.
Step-by-Step: Reimbursement Claim Process
Intimate the insurer within 24–48 hours of hospitalisation (planned: before; emergency: within hours). Call the insurer's helpline or use the app.
Collect all original documents at discharge: original bills, payment receipts, discharge summary, all test reports, prescriptions, doctor's certificate, OT notes if surgical procedure.
Fill the claim form accurately — available on insurer's website or app. Submit within 15–30 days of discharge (check your policy for exact deadline).
Submit all documents to insurer's claims department — physically or digitally via their claims portal or app. Keep copies of everything submitted.
Insurer reviews within 7–30 days. They may request additional documents. Respond promptly to avoid delays.
Settlement — insurer transfers approved amount directly to your bank account. They will deduct non-covered items per policy terms.
Whether cashless or reimbursement, the most important step is timely intimation. Call the insurer's helpline or send a WhatsApp/message via their app as soon as possible after admission. Delayed intimation is one of the common technical reasons for claim rejection or reduction. Most insurers allow emergency intimation within 24 hours; planned hospitalisation must be pre-intimated.
Cashless vs Reimbursement: Key Differences
| Factor | Cashless Claim | Reimbursement Claim |
|---|---|---|
| Where available | Network hospitals only | Any hospital in India |
| Cash requirement upfront | Minimal (only non-covered items) | Full bill amount upfront |
| Speed | Faster — insurer settles directly | Slower — 15–30 days after discharge |
| Documentation at discharge | Hospital handles majority | Patient collects all originals |
| Claim approval timing | Pre-authorised before/during treatment | Post-hospitalisation review |
| Risk of rejection | Lower — pre-approved | Higher — post-hoc review |
Why Claims Get Rejected — And How to Avoid It
- Non-disclosure: Medical conditions not mentioned at policypurchase (diabetes, hypertension, previous surgeries)
- Waiting period: Claiming for a condition still within thepre-existing disease waiting period
- Policy exclusions: Purely cosmetic procedures, self-inflictedinjuries, infertility (in many policies), lifestyle diseases in some older policies
- Late intimation: Hospitalization not informed to insurer withinthe stipulated timeline
- Incomplete documents: Missing original bills, discharge summary,or prescriptions during reimbursement claims
- Non-network hospital without prior approval
For a planned surgery at a network hospital, when should you ideally inform your health insurer?
Key Takeaways
- Cashless claims require pre-authorisation at network hospitals — contact the insurance desk 3–5 days before planned admission
- Always intimate your insurer within 24–48 hours of any hospitalisation — emergency or planned — late intimation is a common rejection reason
- For reimbursement claims, collect all original bills, prescriptions, discharge summary, and test reports before leaving the hospital
- Most claims are rejected due to non-disclosure, waiting period violations, or missing documents — not insurer bad faith. Transparency and preparation prevent it