Cashless Health Insurance Claims

Health insurance claims can be cashless or reimbursement.

Cashless claims

At a network hospital (one with an agreement with your insurer):

1. Show your health card and ID at admission.
2. The hospital sends a pre-authorisation request to the insurer or third-party administrator (TPA).
3. The insurer approves an amount.
4. At discharge, the insurer pays the hospital directly, and you pay only non-covered items.

Reimbursement claims

At non-network hospitals, you pay the bill and later submit documents to the insurer for reimbursement.

IRDAI’s 2024 rules

In May 2024, IRDAI’s master circular on health insurance required insurers to:

• Decide on cashless authorisation requests within one hour.
• Approve final discharge within three hours of the hospital’s request.
• Aim for 100 percent cashless settlement where possible.

Delays beyond deadlines may require insurers to bear extra costs charged by hospitals.

Common problems

• Room rent limits: choosing a room above the limit can reduce the whole claim proportionally.
• Non-payable items: consumables like gloves and masks.
• Co-payments and sub-limits.
• Pre-existing disease waiting periods.

Tips

• Check your network hospitals in advance.
• Understand room rent limits.
• Keep a copy of the policy.
• For planned treatments, seek pre-authorisation early.