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Health Claim Guide · 18-45 days from final document submission

Health insurance reimbursement claim filing

The documents to collect, the order of events, and the 30-day IRDAI settlement clock.

A reimbursement claim is the process by which you pay the hospital bill upfront and recover the admissible portion from your health insurer afterwards by submitting documents. It is the standard fallback when the hospital is outside the insurer's empanelled network, when an emergency admission was too rushed for pre-authorisation, or when cashless was attempted and denied. Reimbursement is administratively heavier than cashless — every paper trail you forgot to collect at the hospital becomes a query later — but the underlying right to be paid is the same. The IRDAI Health Insurance Regulations and the Master Circular on Health Insurance set the regulatory clock. Insurers must settle or formally deny a clean reimbursement claim within 30 days of receiving the last required document. If the insurer needs an investigation, the regulator allows up to 45 days from the date of last document, and any delay beyond that attracts interest at a rate two percentage points above the bank rate. In practice, a complete and well-organised reimbursement file gets settled in 18-25 days; a file with missing documents or unclear bills can drag for 60+ days through query-and-response cycles. This guide walks through the end-to-end sequence: intimation, paying the hospital, document assembly, the claim form, submission, follow-up, settlement via NEFT, and what to do if the insurer settles only partially or denies. The worked example used throughout is a ₹3.2 lakh non-network nursing-home bill that ultimately settles at ₹2.95 lakh after ₹25,000 of inadmissible items and a clean 22-day timeline.

Before you start — keep these ready

  • Insurer / TPA helpline number from the back of the policy card
  • Policy schedule and the latest renewal certificate
  • Patient KYC — Aadhaar, PAN, address proof
  • Cancelled cheque or bank statement of the policyholder for refund credit
  • ₹3-4 lakh in liquid funds or a credit card with sufficient limit for the upfront hospital payment
  • A folder labelled 'claim' to hold every receipt, prescription, and report from day one

Step-by-step

  1. 1

    Intimate the insurer within 24-48 hours

    Within 24-48 hours of admission

    Call the insurer's helpline, log a claim on the mobile app, or message the TPA on the channel listed on your policy card. Most policies require intimation within 24 hours of an emergency admission and 24-48 hours of a planned admission. Note down the claim reference number — every document you send later must carry it.

    • If the patient is unconscious, a family member can intimate using the policy number
    • Save the SMS or email confirming intimation; it is the only proof of timely notice
  2. 2

    Pay the hospital bill upfront

    At discharge

    At discharge, settle the hospital bill in full. Pay through traceable channels — UPI, NEFT, debit or credit card, or a cheque — never cash beyond ₹2 lakh in aggregate for any single transaction (Section 269ST of the Income Tax Act). Collect a stamped final bill and itemised payment receipt against every payment instrument you used.

  3. 3

    Collect the full document set before leaving the hospital

    At discharge

    The hospital must hand you the original itemised final bill, the discharge summary signed by the treating doctor, every investigation and pathology report, every prescription, and every payment receipt. Ask the doctor to fill the treating-doctor section of your insurer's claim form on the spot — chasing a doctor's signature after discharge is the single most common source of delay.

    • Take photographs of every original document before submission as backup
    • Ask for a hospital registration certificate or letterhead — IRDAI definitions require a minimum bed count and 24x7 nursing
  4. 4

    Fill the claim form and arrange a cancelled cheque

    Within 7 days of discharge

    Download the insurer's claim form (typically split into Part A — policyholder declaration; Part B — treating doctor; Part C — hospital). Fill Part A in full, attach a cancelled cheque or a bank statement of the policyholder showing IFSC and account number for NEFT credit. The bank account must be in the policyholder's name — credit to a third-party account is not permitted under IRDAI rules.

  5. 5

    Submit the complete claim within 15-30 days of discharge

    Within 15-30 days of discharge

    Submit the full bundle — claim form, original final bill, discharge summary, all investigation reports, all prescriptions, all payment receipts, KYC, cancelled cheque, and a cover letter listing the contents — to the insurer either through the online portal with scanned documents or by registered post / courier with acknowledgement. Most policies set a 15 or 30 day filing window from the date of discharge.

    • Number every page of the bundle and list them in your cover letter
    • Keep certified photocopies of everything you submit; if originals are lost in transit you have a fallback
  6. 6

    Respond promptly to insurer queries

    Within 7 days of each query

    The insurer may raise a query within 7-15 days asking for an additional document — a missing prior consultation note, a clearer copy of an investigation report, a clarification on a discrepant date. Respond on the same channel and within the deadline the insurer specifies (usually 7 days). Repeated query cycles are the main reason a 'simple' reimbursement claim drifts past 30 days.

  7. 7

    IRDAI 30-day settlement clock starts on complete documents

    From acknowledgement of last document

    The 30-day settlement timeline runs from the date the insurer acknowledges receipt of the last required document, not from the date of original submission. Keep email confirmations or registered-post acknowledgements for every document you send so you have a clean record of when the clock should have started.

  8. 8

    Receive settlement via NEFT or RTGS

    Within 7 working days of approval

    On approval, the insurer credits the admissible amount to the policyholder's bank account by NEFT or RTGS, usually within 7 working days of approval. You receive a settlement letter (or 'claim closure' email) listing the total claim amount, the admissible amount, every line of deduction with reasons, and the net amount paid.

  9. 9

    Review the settlement letter for partial deductions

    Within 30 days of settlement

    Compare the deductions line-by-line against your policy document. Common deductions are room-rent proportional reductions, consumables not on the policy schedule, deductible / co-pay amounts, and any item the insurer treats as non-medical. If a deduction is incorrect — for example the room rent was within the cap — write to the insurer with the policy clause cited.

  10. 10

    Escalate a denial or short-payment in the right order

    Within 30 days of partial settlement or denial

    If the insurer denies the claim or pays materially less than expected, the escalation order is: insurer's grievance redressal officer (15-day window) → IRDAI Bima Bharosa portal → Insurance Ombudsman (jurisdiction up to ₹50 lakh, free, no lawyer needed) → consumer forum or civil court. A separate guide on this site covers each escalation step in detail.

Common pitfalls

  • Do not delay intimation past the policy window — late intimation is one of the top three reasons cited for repudiation, even when the underlying claim is genuine
  • Do not submit photocopies of original bills as your primary submission; insurers require originals and any duplicate is treated as suspicious
  • Do not pay the hospital in cash beyond ₹2 lakh in aggregate (Section 269ST) — the corresponding receipt may not be honoured by the insurer's audit team
  • Do not assume a hospital with under 10 beds qualifies — IRDAI definitions require minimum bed counts (10 in metro, 15 in non-metro), 24x7 nursing, and a registered medical practitioner
  • Do not let the doctor's claim form section stay blank — chasing a treating doctor for a signature after the patient has been discharged often takes weeks
  • Do not accept a verbal 'we will settle' — every approval, partial settlement, or denial must come in writing with a settlement letter

Frequently asked questions

Worked example: ₹3.2 lakh non-network nursing-home bill
On a ₹5 lakh sum insured policy with no co-pay, you pay the ₹3.2 lakh bill upfront, intimate within 24 hours, and submit complete documents on day 5 post-discharge. The insurer raises one query on day 12, you respond on day 14, and on day 22 the insurer settles ₹2.95 lakh by NEFT after deducting ₹15,000 of consumables and ₹10,000 of administrative items.
How long does the IRDAI 30-day settlement clock take to actually start?
It starts from the date the insurer acknowledges receipt of the last required document, not from your first submission. If the insurer raises three rounds of queries, the clock effectively restarts each time the last document of that round is submitted. Keep dated acknowledgements for every document you send.
What documents are most commonly missed?
The doctor's section of the claim form (because the doctor has gone home by discharge), the original itemised final bill (hospitals sometimes hand only a summary), payment receipts in the policyholder's name (if a relative paid by their card), and any investigation report dated before admission that the insurer treats as 'pre-existing investigation'.
Can I file reimbursement if I forgot to intimate within 24 hours?
Yes, technically. IRDAI circulars and consumer-forum rulings have softened the strict reading of the intimation clause for genuine claims. Submit the file with a written explanation for the delay. A long, unexplained delay can still become a ground for repudiation, so document the reason (medical emergency, family in shock, IT outage at the insurer) honestly.
What is the difference between a deductible and a co-pay deduction?
A deductible is a fixed rupee amount you bear on every claim before the insurer pays anything — typical on super top-ups (₹3-10 lakh deductibles). A co-pay is a percentage you bear on the admissible bill — typical on senior-citizen plans (10-20%). Both reduce the net settlement; check your policy schedule for which (if any) applies.
Is there interest if the insurer delays beyond 30 days?
Yes. Under the IRDAI Master Circular, an unjustified delay beyond the 30-day window from receipt of last document attracts interest at a rate two percentage points above the prevailing bank rate, payable from the day after the deadline until the actual settlement date. You must claim this interest in writing — it is not paid automatically.
What if the insurer denies the claim entirely?
The insurer must give written reasons. Read the policy clause cited and check whether the reason is factually correct. The escalation order is the insurer's grievance redressal officer, then the IRDAI Bima Bharosa portal, then the Insurance Ombudsman (free, jurisdiction up to ₹50 lakh, no lawyer needed). Most disputes settle at one of these three levels.

Further reading