🏥 Health Insurance Claim Procedure in India – Step-by-Step Guide, Documents, Dos & Don’ts, and Remedies for Denied Cashless Claims

📌 Introduction: Why Understanding the Health Insurance Claim Procedure Matters

Health insurance in India is meant to ease the financial burden during medical emergencies. But many policyholders struggle with delayed claim settlements, cashless claim denials, or reimbursement issues—often because they don’t know the right procedure.

This guide from iClaimSupport will walk you through:

✅ How to file a health insurance claim in India
✅ Step-by-step cashless and reimbursement claim processes
✅ Required documents for health insurance claims
✅ Dos and Don’ts while filing a claim
✅ Legal remedies if your cashless claim is denied

💳 Types of Health Insurance Claims in India

There are two primary types of health insurance claims:

1. Cashless Claim – Where the insurance company settles the bill directly with the network hospital

2. Reimbursement Claim – Where you pay the hospital bill and claim it back later from the insurer

Let’s understand the procedure for both in detail.

✅ Step-by-Step Process: Cashless Health Insurance Claim in India

🏥 For Planned Hospitalization:

Choose a Network Hospital
Ensure the hospital is on your insurer’s network hospital list.
Pre-Authorization Form Submission
Submit a cashless pre-authorization request at least 3–5 days before the admission date.
Approval from Insurer or TPA
The insurance company/TPA reviews the request and shares a cashless approval letter with the hospital.
Treatment and Discharge
The patient undergoes treatment; final bill is submitted to the insurer.
Claim Settlement
The insurer pays the hospital directly. Non-covered expenses like food, consumables, and admin charges must be paid by the patient.

🚑 For Emergency Hospitalization:

Reach a Network Hospital Quickly
Provide your health insurance card and ID proof at admission.
Hospital Sends Emergency Intimation
Hospital initiates the cashless request after stabilizing the patient.
Provisional Approval and Treatment
Insurer gives immediate approval if the claim falls within coverage.
Final Claim Submission and Settlement
Final bill and treatment summary are sent for approval and payment.

💼 Reimbursement Claim Process in Health Insurance

If treatment happens in a non-network hospital or your cashless claim is denied, you can claim reimbursement.

Step-by-Step Reimbursement Process:

Pay Hospital Bills Upfront
Settle the full bill amount at discharge.
Collect All Medical Documents
Ensure you take original discharge summary, invoices, test reports, and prescriptions.
Fill the Reimbursement Claim Form
Available on the insurer’s website or through their app.
Submit All Documents
Submit to the insurer/TPA within 7–15 days of discharge (check your policy conditions).
Claim Review and Approval
Once verified, the insurer transfers the eligible amount to your bank account.

📄 Documents Required for Health Insurance Claim

Keep the following documents ready to avoid delays:

Health insurance policy/cashless card
Valid government ID proof (Aadhaar, PAN, Voter ID)
Duly filled claim form
Discharge summary from hospital
Final hospital bill with break-up
Doctor’s prescriptions
Pharmacy and diagnostic bills
Medical test reports (X-ray, CT, blood tests, etc.)
NEFT/cancelled cheque for payment (reimbursement claims)

⚠️ Common Mistakes to Avoid – Dos and Don’ts in Health Insurance Claims

✅ Dos:

Inform your insurer/TPA immediately—within 24 hours in case of emergencies
Use network hospitals for cashless benefit
Keep copies of all documents you submit
Read your policy inclusions, exclusions, and sub-limits carefully
Always insist on detailed itemized bills

❌ Don’ts:

Don’t delay claim intimation—this is a common reason for rejection
Don’t hide pre-existing illnesses or past treatments
Don’t assume all expenses are covered—read fine print
Don’t discard prescriptions, receipts, or test reports
Don’t sign blank forms or undisclosed declarations

🚫 What to Do If Cashless Claim is Denied?

Even if your cashless request is denied, it does not mean your entire claim is rejected. You can still pursue reimbursement or raise a dispute.

🔄 Alternative Options:

File a Reimbursement Claim
Submit all documents and claim the amount directly.
Approach the Insurer’s Grievance Cell
Every insurer must resolve complaints within 15 working days.
Escalate to IRDAI or Insurance Ombudsman
If not resolved, file a complaint with the IRDAI’s Integrated Grievance Management System (IGMS) or the Insurance Ombudsman.
Consumer Court Remedy
If your claim is unfairly denied or underpaid, you can take legal action under the Consumer Protection Act.

⏱️ IRDAI Claim Settlement Timelines

Keyword Focus: IRDAI health insurance rules, claim settlement timelines

Claim Activity	IRDAI Prescribed Time Limit
Cashless approval (planned)	Within 3–4 working hours
Reimbursement claim settlement	Within 30 days after receiving documents
Grievance resolution by insurer	Within 15 days
Final redressal by IRDAI	After 30 days from initial complaint

⛔ If delays occur beyond these limits without justification, insurers are liable to pay 2% interest above RBI bank rate on the claim amount.

🛡️ iClaimSupport Can Help You Get Your Claim Approved

At iClaimSupport, we assist individuals and families who are facing:

Wrongful claim rejections or deductions
Cashless treatment denials despite policy coverage
Delayed or underpaid settlements
Lack of communication from insurers or TPAs

We take up your case, fight on your behalf, and if necessary, pursue the matter before the Consumer Forum.

📞 Need Help With a Health Insurance Claim?

You paid your premiums—now let your policy work for you. If your genuine claim has been rejected or delayed, don’t stay silent. Talk to our experts today.

📧 Email: contact@iclaimsupport.in
📱 Phone: 9871820066
🌐 Website: www.iclaimsupport.in

🔚 Final Words

Filing a health insurance claim in India doesn’t have to be overwhelming. With the right knowledge, documents, and support, you can get what you’re entitled to.

📌 Bookmark this guide. Share it with your family. And remember—if things go wrong, iClaimSupport is here to help.