Step-by-Step Guide: Filing a Health Insurance Claim

What documents you need, who to contact, and how to speed up approvals.

Filing a health insurance claim can be stressful — especially during a medical emergency.
This guide explains the complete step-by-step process for both cashless and reimbursement claims,
required documents, timelines, common pitfalls, and how to follow up until closure.

1. Two Types of Claims

A) Cashless Claim

• Available only at insurer network hospitals.
• Hospital coordinates with insurer/TPA and bill is settled directly.
• Best for planned & emergency hospitalisations.

B) Reimbursement Claim

• You get treated (any hospital), pay the bill, and submit for reimbursement later.
• Requires original bills, reports and claim form for settlement.

2. Check Network Hospital Before Admission

For cashless claim, always verify the hospital is in your insurer’s network via the insurer’s website/app or helpline.

3. Timely Intimation to Insurer

• Emergency hospitalisation: Inform insurer / TPA within 24 hours.
• Planned hospitalisation: Inform 48–72 hours before admission.
• Intimate via customer-care call, insurer app/portal or hospital insurance desk.

4. Pre-Authorization (Cashless Only)

At the hospital insurance/help desk:

1. Fill the pre-authorization form.
2. Submit KYC (Aadhaar/PAN), policy ID and doctor’s admission notes.
3. Hospital sends request to insurer/TPA for approval.

Typical approval time: 30–90 minutes (can vary).

5. Documents You Must Keep Ready

For Cashless:

• Policy ID / e-card
• Aadhaar / PAN
• Doctor’s admission note & pre-authorization form

For Reimbursement (after discharge):

• Filled claim form (insurer format)
• Original hospital bills & receipts
• Discharge summary & doctor’s notes
• Diagnostic reports, prescriptions
• Payment proof (cash/UPI/cheque)

6. During Treatment — Track Claim Status

• For cashless: hospital and insurer exchange status updates; you should receive SMS/email.
• For reimbursement: keep all originals safe and track via insurer portal after submission.

7. Pay Non-Covered Items

Even with cashless approvals, you may need to pay for:

• Registration/admission deposit
• Consumables (gloves, disposable items)
• Food & attendant charges, extra bed
• Items excluded by policy

8. Submitting Reimbursement Claim — Post Discharge

1. Fill & sign insurer’s claim form.
2. Attach all original bills, prescriptions, reports and discharge summary.
3. Submit at insurer / TPA branch or upload via portal/app.
4. Keep acknowledgement / submission receipt.

Processing time commonly ranges from 7–21 working days (subject to insurer/TPA).

9. Follow Up Until Closure

• Check SMS/email updates and portal status regularly.
• If insurer requests additional docs, submit immediately to avoid delays.
• Maintain a record of all communications (emails, call logs, receipts).

10. If Your Claim Is Delayed or Rejected

1. Ask insurer/TPA for the exact reason in writing.
2. Collect any missing or corrected hospital documents (discharge summary, doctor note).
3. File a claim appeal / reconsideration with supporting documents.
4. Escalate to Grievance Redressal Officer → IRDAI (IGMS) → Insurance Ombudsman if unresolved.

Quick Checklist (Printable)

Final Tips

• Always disclose past medical history honestly to avoid claim rejection.
• Pay premiums on time — lapsed policies cause rejections.
• Prefer network hospitals for faster cashless settlement.
• Keep digital & physical copies of all medical documents.

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