Health Insurance Cashless Claim: IRDAI Timelines, Steps and What to Do if It Is Denied

In a cashless claim, your health insurer pays the hospital directly, so you do not have to arrange a large amount at the time of treatment. Here is how it works and what the insurance regulator IRDAI says.

Cashless and reimbursement

• **Cashless:** treatment at a network hospital that has a tie up with your insurer. The insurer or its Third Party Administrator (TPA) settles the bill directly.
• **Reimbursement:** you pay the hospital first and then claim the money from the insurer with bills and documents.

Steps for a cashless claim

1. Check that the hospital is in your insurer’s network list, on the insurer’s website or app.
2. At admission, show your health card or policy number and ID at the insurance desk.
3. The hospital sends a pre authorisation request to the insurer or TPA with medical details.
4. For planned treatment, start this process a few days in advance. For emergencies, inform the insurer within the time stated in the policy, often 24 hours.
5. At discharge, the hospital sends the final bill for approval. You pay only for items not covered, such as some consumables, and any co payment or deductible.

IRDAI timelines

Under the IRDAI Master Circular on health insurance issued in May 2024, insurers must decide on cashless authorisation requests within one hour of receiving them. Final authorisation at discharge must be given within three hours of the request from the hospital. If there is a delay beyond three hours, extra charges by the hospital are to be borne by the insurer as per the circular. Insurers were also asked to move towards fully cashless claims.

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Why cashless can be denied

• Hospital is not in the network
• Treatment is not covered or falls under a waiting period
• Missing documents or incomplete medical details
• Policy has lapsed or the sum insured is used up

Denial of cashless does not always mean the claim is rejected. You can still apply for reimbursement with all documents.

How to complain

1. First write to the insurer’s grievance officer.
2. If you are not satisfied within the set time, use IRDAI’s Bima Bharosa portal or call the IRDAI toll free number listed on its website.
3. You can also approach the Insurance Ombudsman for claims within its limits.

Tips

• Read the policy wording for room rent limits, sub limits and exclusions.
• Keep copies of all reports and bills.
• Update the insurer about changes in contact details.

Bottom line

Use network hospitals, start pre authorisation early and know your rights under IRDAI rules to make cashless claims smoother.

Source / स्रोत: IRDAI, Bima Bharosa grievance portal