Quick answer. At a network hospital, the desk sends your insurer a pre-authorisation request. IRDAI requires a decision within one hour, and final discharge approval within three. Other claims must settle within 15 days. If refused, ask for the clause in writing. Complain to the insurer, then Bima Bharosa, then the Insurance Ombudsman, which is free.
A hospital desk asking about your insurance is the last thing you want to deal with when someone is unwell. It helps to know what the insurer has to do, and how fast. This guide covers how a cashless claim works, what the Insurance Regulatory and Development Authority of India (IRDAI) requires, why claims get refused, and where to complain. It is general information, and your policy wording decides the details.
The time limits IRDAI sets
| Step | Rule | Source |
|---|---|---|
| Cashless request | Decision immediately, and within one hour of receiving the request | Health master circular, para 15 |
| Final approval at discharge | Within three hours of the hospital’s discharge request. You should not be made to wait to be discharged | Para 16 |
| Delay beyond three hours | Any extra hospital charge is paid by the insurer from its shareholders’ funds | Para 16 |
| Death during treatment | Claim processed immediately, and the body released from hospital immediately | Para 16 |
| Claims other than cashless | Settled within 15 days of submission | Policyholder master circular, Part B |
| Late settlement | Interest at bank rate plus 2%, from the date of intimation to payment, paid without your having to ask | Part B |
| Your complaint to the insurer | Immediate acknowledgement, and a resolution within 14 days | Part B |
| Ombudsman award | Insurer must comply within 30 days of receiving it, or pay Rs 5,000 a day to you, unless it appeals | Part B |
These rules date from the Master Circular on Health Insurance Business of 29 May 2024 and the Master Circular on Protection of Policyholders Interests of 2024. The one-hour rule had to be in place by 31 July 2024. We found no later IRDAI circular changing these limits when we checked on 2 November 2026.
How a cashless claim works
In a cashless claim, you are treated at a hospital in your insurer’s network, and the insurer or its Third Party Administrator (TPA) pays the hospital directly. Costs above your limits or sub-limits, and anything your policy does not cover, you settle yourself.
- Check the hospital. Ask your insurer, TPA or the hospital’s insurance desk whether the hospital is in your network. Cashless is not available at a hospital outside the network.
- Carry your details. Keep your health card or policy number and photo ID to hand.
- Tell the insurer. For planned treatment, do this as early as you can. In an emergency, focus on the patient and have someone contact the insurer or desk as soon as possible.
- Request pre-authorisation. The hospital’s insurance desk usually sends this request with the doctor’s notes and an estimate. The insurer must also offer pre-authorisation digitally.
- Wait for the decision. The clock runs from the time the request reaches the insurer, so ask the desk when it was sent.
- Watch the running bill. If treatment changes or the estimate grows, ask the desk to send an updated request.
- At discharge. The hospital sends a final request. The insurer has three hours. Before signing, ask for an itemised list of anything you must pay yourself.
- Keep copies. Keep the discharge summary, the final bill, the approval letter and your payment receipts.
You should not have to collect paperwork for the insurer. After intimation, the insurer and TPA must collect the documents they need from the hospital.
If you hold more than one policy
For regular indemnity policies, you can choose which policy to claim from. That insurer becomes the primary one, and if your cover falls short, it has to coordinate with the others for the balance. For benefit-based policies, you can claim from each insurer.
Employer policies
If you are covered through work, no claim may be denied because the insurer does not yet have your details as a group member, and claims are paid directly to the employee or beneficiary.
If cashless is refused: reimbursement
A refused cashless request may not be the end of your claim. Ask for the reason in writing, then ask your insurer whether you can pay the hospital and claim the money back, based on your policy terms.
- Tell the insurer about the claim at the earliest, by phone, online, through the TPA or via the hospital.
- Get every paper before you leave: discharge summary, bills, reports, prescriptions and payment receipts. Copies of tests matter.
- Submit the claim form and papers by the method in your policy, and note the date.
- The insurer must settle within 15 days of submission. If it is late, interest is due.
IRDAI says no claim shall be rejected or closed for want of documents or for delayed intimation. So if you were late or a paper is missing, please still file, and explain why.
Common reasons a claim is refused or cut
Disputes often turn on a few parts of the policy. Your Customer Information Sheet, which the insurer must give you with the policy, sets out each of them in simple words. It is the first thing to read.
| Reason | What it means | What you can check |
|---|---|---|
| Waiting period | A time during which certain illnesses or treatments are not covered. A new policy generally has a 30-day wait, with exceptions such as accidents. | Your policy start date and the wait for this condition. Credits from an earlier policy may count if you ported or migrated. |
| Pre-existing disease | An illness existing before the policy. Policies usually have a set wait for these. | How your policy defines it, and how long you have been covered. |
| Non-disclosure | The insurer says you did not reveal something when you bought the policy. | After 60 months of continuous cover, the moratorium means this can only be raised for established fraud. |
| Exclusion | Your policy does not cover this item or treatment. | The summary of exclusions. IRDAI gives examples such as spectacles and hearing aids, though wordings differ. |
| Sub-limit | A cap on a part of the bill, such as room rent or a named procedure. | The sub-limits in your sheet. These often explain a partly paid bill. |
| Deductible | An amount you pay before the insurer pays. | The amount in your policy. |
| No in-patient need | The insurer says admission was not medically needed. | Ask your doctor for a note explaining why admission was needed. |
| Outside the network | The hospital is not a network hospital, so cashless does not apply. | Reimbursement may still be possible. |
| Delays and missing papers | These alone should not close a claim. | Quote the policyholder circular. |
What the insurer must tell you
A claim cannot be rejected casually. Rejection needs approval from the insurer’s Product Management Committee or its Claims Review Committee. If a claim is rejected or partly paid, the insurer must give you full details, with reference to the specific terms of the policy. If a letter just says “not payable”, ask for the clause.
How to complain, in order
1. The insurer
Complain through a branch, letter, email, website or call centre. Your insurer must acknowledge it at once and resolve it within 14 days, giving reasons with reference to the policy. The reply must also tell you which Insurance Ombudsman to go to.
2. Bima Bharosa, IRDAI’s portal
You can register and track a complaint on Bima Bharosa, which links to insurers’ own systems. Or call the IRDAI Grievance Call Centre on 155255 or 1800 425 4732, from 8 am to 8 pm, Monday to Saturday. The portal never asks for payment, so treat any such demand as a fraud, and watch for lookalike sites.
3. The Insurance Ombudsman
The Council for Insurance Ombudsmen gives these conditions:
- You must have complained to the insurer first.
- You can go to the Ombudsman if the insurer has rejected your complaint, you are unhappy with its response, or it has not replied within one month.
- File within one year of the rejection, or of the end of that month.
- The compensation you seek must not exceed Rs 50 lakh.
- It is free of charge. You can apply in person, by post, by email or online.
Include your policy and claim numbers, your complaint to the insurer, its reply, the rejection letter and your bills. Older websites may still mention a lower limit, so please go by the Council’s own site.
Common questions
Does the one-hour rule mean my claim must be approved in an hour?
It means the insurer must decide within an hour of receiving the request. The answer could be approval, a part approval, a question or a refusal. The circular sets the time limit and does not promise a yes.
The hospital says I must wait for insurer approval to go home. Is that allowed?
IRDAI says you should not be made to wait to be discharged. Ask the desk what time the request went to the insurer, then call your insurer. If it has gone past three hours, any extra hospital charge falls on the insurer.
Can a claim be rejected because I told the insurer late?
The policyholder circular says no claim shall be rejected or closed for delayed intimation. Tell the insurer as soon as you can, though.
Where can I find a doctor or hospital to get a second view?
You can use find a doctor, or our specialist finder. Please confirm with your insurer that a hospital is in your network.
Sources
- IRDAI Master Circular on Health Insurance Business, 29 May 2024, checked 2 Nov 2026.
- IRDAI Master Circular on Protection of Policyholders Interests, 2024, Part B, checked 2 Nov 2026.
- IRDAI consumer education website, health insurance questions, checked 2 Nov 2026.
- IRDAI consumer affairs: grievance system and call centre, checked 2 Nov 2026.
- Bima Bharosa complaint portal, IRDAI, checked 2 Nov 2026.
- Council for Insurance Ombudsmen: conditions and ways to complain, checked 2 Nov 2026.
- Online complaint, Council for Insurance Ombudsmen, address as given in the IRDAI circular, checked 2 Nov 2026.