A health insurance claim works one of two ways. In a cashless claim, the network hospital asks your insurer or its third-party administrator (TPA) for approval and the insurer pays the hospital directly. In a reimbursement claim, you pay the bill and then claim the money back. Under IRDAI’s master circular of 29 May 2024, insurers must decide a cashless request within one hour and give final discharge approval within three hours of the hospital’s request, the Finance Ministry told the Lok Sabha in December 2025.
Those time limits have applied since 1 August 2024. The same circular says policyholders should not have to submit documents for claim settlement because insurers and TPAs collect them from the hospital, and no claim can be rejected without approval from a claims review committee. If something still goes wrong, Chennai residents can escalate to IRDAI’s Bima Bharosa portal and the Insurance Ombudsman at Teynampet.
Before you start
| Document | Who needs it | Notes |
|---|---|---|
| Policy number or e-card | Everyone | Shown at the hospital insurance desk |
| Photo ID of the patient | Everyone | Matches the name on the policy |
| Doctor’s advice for admission | Planned admissions | Needed for pre-authorisation |
| Original bills, discharge summary, reports | Reimbursement claims | Keep copies before submitting |
| Cancelled cheque or bank details | Reimbursement claims | For payment of the claim |
Source: IRDAI master circular of 29 May 2024; insurer’s claim form
How to make the claim
- Check if the hospital is in your network. Your insurer’s app or website lists network hospitals. Cashless works only there; elsewhere you pay and claim reimbursement.
- Inform the insurer early. For a planned admission, tell the insurer or TPA in advance. For an emergency, tell them as soon as the patient is stable; the policy wording sets the deadline.
- Hand your e-card to the insurance desk. The hospital sends the pre-authorisation request. The decision is due within one hour, a timeline met in 86.88% of requests between August 2024 and May 2025, according to the Lok Sabha reply.
- Track the approval at discharge. Final authorisation is due within three hours of the hospital’s request. Ask the desk to send it promptly when the doctor clears discharge.
- Pay only non-payables and your share. Items the policy excludes, and any co-payment, are billed to you. Ask for an itemised bill.
- For reimbursement, file the claim form. Submit the claim form with original bills, the discharge summary, reports and bank details within the period your policy states.
- Read the settlement letter. Check every deduction against the policy wording. A rejection has to be cleared by the insurer’s claims review committee.
- Escalate if needed. Complain to the insurer’s grievance officer first, then Bima Bharosa, then the Ombudsman.
Timelines and escalation
| Stage | Time limit | Where |
|---|---|---|
| Cashless pre-authorisation | Within 1 hour | Insurer or TPA, via hospital desk |
| Final discharge approval | Within 3 hours of hospital’s request | Insurer or TPA |
| Grievance with insurer | Attended to within 14 days | Insurer, tracked on Bima Bharosa |
| Insurance Ombudsman | After 30 days without a reply, within one year | Chennai office, Teynampet |
Source: Lok Sabha reply, 1 December 2025; Bima Bharosa; Council for Insurance Ombudsmen
An insurer that does not implement an Ombudsman award within 30 days must pay the policyholder ₹5,000 a day, under the 2024 master circular.
Common mistakes
- Assuming any hospital is cashless. Check the network list before admission, not at the billing counter.
- Missing the intimation deadline in your policy. Late notice is a common reason for disputes.
- Submitting originals without keeping copies. You may need them for an appeal.
- Paying an agent who promises to ‘get the claim passed’. Bima Bharosa warns that it never asks for payment.
If it goes wrong
Write to the insurer’s grievance officer with your claim number. If the issue is not resolved, register it on Bima Bharosa, which links to insurers’ complaint systems and says complaints are attended to within 14 days. If there is no reply within a month or you are unhappy with it, approach the Insurance Ombudsman within one year; there is no fee, and you can file online, by email or in person, according to the Council for Insurance Ombudsmen. The Chennai office is at Fatima Akhtar Court, 4th Floor, 453 Anna Salai, Teynampet, and covers Tamil Nadu, Puducherry town and Karaikal. Hospital billing disputes can also go to the National Consumer Helpline on 1915.
Policies differ in their exclusions and waiting periods. For a large or disputed claim, it may help to speak to an independent financial or legal adviser.
Quick answers
How fast must a cashless claim be approved?
Within one hour for the initial request and three hours for final discharge approval, under IRDAI’s 2024 master circular.
Do I have to submit documents for a cashless claim?
The circular says insurers and TPAs should collect documents from the hospital, not from you.
Where is the Insurance Ombudsman in Chennai?
Fatima Akhtar Court, 4th Floor, 453 Anna Salai, Teynampet, Chennai 600018.
Is there a fee to complain to the Ombudsman?
No. Complaints are free and can be filed online at cioins.co.in.
Information checked against official sources on 19 October 2026. Fees, dates and rules can change; confirm on the linked official pages before acting.
Sources
- Lok Sabha Starred Question 20 on health insurance claims, answered 1 December 2025 (Ministry of Finance)
- Bima Bharosa grievance portal (IRDAI)
- Council for Insurance Ombudsmen: how to complain
- Offices of the Insurance Ombudsman (Council for Insurance Ombudsmen)
- National Consumer Helpline (Department of Consumer Affairs)
