How to File a Health Insurance Claim in India

Filing a health insurance claim correctly and promptly significantly impacts how quickly and fully you get reimbursed. There are two modes of claims in India — cashless and reimbursement — each with distinct steps. For cashless claims at network hospitals: before elective admission, inform your insurer or TPA (Third Party Administrator) 48-72 hours in advance through the cashless pre-authorisation request.

For emergency admission, inform within 24 hours. At the hospital, present your health insurance card (physical or digital) at the insurance desk. The hospital TPA desk coordinates with the insurer, sends treatment details, and seeks approval.

The insurer reviews and grants approval for a specified amount. Upon discharge, you pay only the non-covered amounts — co-pay if applicable, non-medical items, and expenses exceeding approval. Get the discharge summary and all documents even for cashless claims, as you may need them for any top-up or second claims.

For reimbursement claims at non-network hospitals: keep all original bills and receipts, discharge summary, operation notes if surgery was performed, investigation reports, prescriptions, and diagnostic reports. Submit the complete claim form from your insurer along with all original documents within the specified timeframe — typically 15-30 days from discharge. Submit by courier with acknowledgement and keep photocopies of everything submitted.

The insurer processes the claim within 30 days of receiving complete documentation by IRDAI regulation. Common reasons for claim delays or partial payment: missing documents, discrepancy between declared age and actual age, treatment for excluded conditions, room rent exceeding policy limit, non-disclosure of pre-existing conditions, and claim for policy exclusions. Knowing these in advance helps you ensure smooth claims.