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Health Claim Guide · Pre-auth 1-6 hours; full stay 3-7 days for typical surgery

Cashless hospital admission — step by step

What the insurance desk, the TPA, and you should each do from admission to discharge, with realistic timelines.

A cashless hospital admission is the process by which an Indian health insurer settles your hospital bill directly with a network hospital, through a Third Party Administrator (TPA), so that you walk out of the hospital without paying the admissible portion of the bill in cash. The mechanism is built into the IRDAI Health Insurance Regulations and is the default expectation of policyholders today, though it works smoothly only when the hospital is on your insurer's empanelled network and the diagnosis is unambiguously covered by your policy. The end-to-end flow has three operational phases. Pre-admission: confirm network status, gather KYC and policy documents, and submit a 'pre-authorisation' request through the hospital insurance desk. During admission: keep treatment-line documentation in order, respond to TPA queries promptly, and pay only the refundable admission deposit and clearly inadmissible items. At discharge: the hospital sends the final bill to the TPA, the TPA approves the admissible portion, you settle the residue (consumables not covered, deductibles, co-pay, room-category-driven proportional deductions if any), and your admission deposit is refunded. IRDAI's 2024 'Cashless Everywhere' framework has tightened the timelines materially — for emergency admissions the regulator has set a target of one hour for pre-authorisation, and for planned hospitalisations the response window is generally 2-6 working hours. This guide walks through the entire sequence with a worked example of a ₹3.8 lakh planned-surgery bill on a ₹10 lakh family-floater sum insured with no co-pay, so you know what to expect at each desk.

Before you start — keep these ready

  • Original policy card or e-card (mobile copy is generally accepted)
  • Policyholder and patient KYC — Aadhaar, PAN, and one address proof
  • Treating doctor's diagnosis note and proposed line of treatment
  • Earlier discharge summaries for any related past hospitalisation
  • ₹15,000-25,000 in your account for the refundable admission deposit
  • Insurer / TPA helpline number from the back of the policy card
  • List of insured family members and their dates of birth (for floater verification)

Step-by-step

  1. 1

    Confirm network status before you go

    24-72 hours before a planned admission; immediately on emergency

    Before a planned admission, call the insurer or TPA helpline and confirm in writing (SMS or email) that the chosen hospital is currently on the cashless network for your specific policy. Network lists are dynamic — hospitals get added and de-empanelled — and a stale list on a brochure is the single most common cause of last-minute confusion. For an emergency, the family member accompanying the patient should make this call from the ambulance or the admission desk.

    • Note the reference / ticket number the helpline gives you
    • Verify the hospital's empanelment for the exact 'health' product you hold, not just the insurer brand
    • Keep a backup network hospital within 30 km in mind in case of last-minute de-empanelment
  2. 2

    Arrive with policy card and KYC ready

    At time of admission

    Reach the hospital insurance desk with the patient's policy card or e-card, the policyholder's PAN and Aadhaar, and the patient's photograph if the desk asks for one. The desk will not begin pre-authorisation until they have a valid policy reference, the patient's identification matched against the policy, and the proposed line of treatment from the treating doctor.

  3. 3

    Hospital insurance desk fills the pre-authorisation form

    Within 30-60 minutes of admission registration

    The hospital insurance desk completes a pre-authorisation form covering provisional diagnosis, ICD-10 code, planned procedure, estimated length of stay, and an itemised cost estimate. You sign the patient declaration and consent. The desk then transmits the request to the TPA either through a portal, by email, or by fax — every TPA still uses at least two of these channels.

    • Verify that the diagnosis code on the form matches what your treating doctor is actually treating
    • Cross-check the cost estimate against the hospital's standard tariff card
  4. 4

    TPA reviews and pre-authorises

    1-6 hours from form submission

    The TPA reviews the request against your policy schedule, your waiting periods, and the medical justification of the treatment. Standard turnaround is 2-6 hours for planned admissions, with a target of one hour for emergency admissions under IRDAI's 'Cashless Everywhere' 2024 framework. The TPA issues either an 'approved' authorisation letter for an initial amount (typically 50-80% of the estimate) or a 'query' asking for additional documents.

  5. 5

    Pay the refundable admission deposit

    At admission

    Even on a cashless admission, hospitals routinely collect a refundable deposit of ₹15,000 to ₹25,000 (sometimes higher for ICU or critical-care admissions) to cover the time gap between admission and final TPA approval. This deposit is adjusted against any inadmissible items at discharge, and the balance is refunded back to your account or card. Keep the deposit receipt — it is needed at discharge.

  6. 6

    Keep treatment-line documentation in order during the stay

    Throughout admission

    Through the stay, the TPA may issue 'enhancement' approvals as the actual line-items evolve — additional days, an unexpected investigation, an upgraded procedure. Make sure the hospital insurance desk forwards these enhancements promptly. If a doctor adds a charge that is not in the original estimate (a special implant, a non-formulary drug), confirm with the desk whether the TPA has approved it before consenting.

    • Keep a daily file of investigation reports and prescriptions in case a query is raised later
    • Ask the duty nurse for an interim itemised bill every 48 hours so there are no surprises at discharge
  7. 7

    Hospital sends the final bill to the TPA at discharge

    Final approval typically within 4-8 hours of bill submission

    When the treating doctor signs the discharge order, the hospital insurance desk compiles the final bill, the discharge summary, all investigation reports, and consent forms, and forwards them to the TPA. The TPA cross-checks the final bill against the approved amounts and issues a 'final authorisation' letter clearing the admissible portion of the bill.

  8. 8

    Settle non-admissible items and any deductible

    At discharge

    The hospital cashier will hand you a residual bill covering items the TPA has flagged as non-admissible: consumables not listed in the policy, attendant bed charges, deluxe room upgrades, registration fees, telephone, and food beyond a reasonable allowance. If your policy has a co-pay or deductible, that amount is also payable now. Pay this residual bill, collect a stamped receipt, and your refundable deposit is reconciled.

    • Insist on a clear breakup of every non-admissible line — do not accept a single 'other charges' figure
    • Common consumables that TPAs deny include gloves, syringes, masks, and dressings packaged together — query each one
  9. 9

    Collect the discharge file and refund of deposit

    At discharge

    Walk out with the original discharge summary, a copy of the itemised final bill, copies of all investigation reports, the TPA approval letter, and a refund receipt for the unused portion of your admission deposit. The hospital should also email a soft copy of the discharge summary within 24 hours.

  10. 10

    Keep all original documents safe for three years

    Post-discharge

    Store the discharge summary, original bill, TPA letters, and all investigation reports in a single labelled folder. They are needed if the TPA later raises a query, if you make a follow-up reimbursement claim for post-hospitalisation expenses (typically covered for 60-90 days), and as evidence in any escalation to the Insurance Ombudsman. The IRDAI grievance window allows up to 3 years for most disputes.

Common pitfalls

  • Do not consent to a deluxe room upgrade without checking your room-rent sub-limit — proportional deduction can scale down every other charge if the policy has a category cap
  • Do not delay informing the insurance desk of a change in line of treatment mid-admission; an unauthorised escalation in cost can become inadmissible later
  • Do not accept the hospital's claim that 'the TPA will sort it out' for an unanswered query — you are the one liable to the hospital for any rejected portion
  • Do not lose the TPA approval letter — it is the single document that proves the cleared amount and is needed for any post-discharge dispute
  • Do not leave the hospital without a stamped final bill and a deposit refund receipt, even if the cashier promises to email them later
  • Do not assume the consumables charge is small — for a multi-day surgical admission it can run ₹15,000-40,000 and is largely inadmissible under most policies

Frequently asked questions

What is the typical time from admission to TPA pre-authorisation approval?
For a planned admission with complete documentation, 2-6 working hours is the norm. For an emergency, IRDAI's 'Cashless Everywhere' 2024 framework has set a target of one hour. Delays beyond 6 hours usually mean a missing document or a query the hospital insurance desk has not closed.
What if cashless pre-authorisation is denied?
You can either pay the bill upfront and file a reimbursement claim later (with full documents and the denial letter), or you can ask the TPA in writing for the specific reason for denial and contest it through the insurer's grievance cell. A separate guide on this site walks through the appeal process.
Worked example: ₹3.8 lakh bill on a ₹10 lakh sum insured floater, no co-pay
Of the ₹3.8 lakh hospital bill, the TPA typically approves ₹3.45-3.55 lakh as admissible. You pay roughly ₹25,000-35,000 at discharge (consumables, attendant bed, telephone, deluxe upgrades) and your refundable deposit is reconciled. The remaining ₹6.45 lakh sum insured is available for the rest of the policy year.
What is the refundable admission deposit for if it is a cashless admission?
It cushions the hospital against the gap between admission and the TPA's final clearance, and against any inadmissible items the TPA flags. Hospitals collect ₹15,000-25,000 for general wards and ₹50,000-1,00,000 for ICU admissions. The deposit is refunded after the final TPA settlement.
Can I use cashless at a non-network hospital under 'Cashless Everywhere'?
IRDAI's 2024 'Cashless Everywhere' initiative permits cashless treatment at non-network hospitals in emergencies, subject to 48 hours' prior notice for planned admissions and 48 hours' notice from admission for emergencies. Adoption across insurers is uneven — call the helpline first and get the approval reference in writing.
What happens if my room category is higher than the policy allows?
If the policy has a room-rent sub-limit and you opt for a higher category, the 'proportional deduction' clause scales down every other charge (surgeon, anaesthesia, ICU, investigations) by the same ratio. A ₹10,000 per day room on a ₹5,000 cap can halve the admissible portion of a ₹4 lakh bill.
How long should I keep the discharge documents after settlement?
At least three years. The discharge summary and itemised bill are needed for post-hospitalisation expense claims (typically 60-90 days), for any TPA query, and as evidence in any grievance escalation. Insurers also rely on past discharge summaries when pricing your renewal premium and assessing pre-existing disclosures.

Further reading