How to make a health insurance claim

A health claim is made in one of two ways. At a network hospital you can ask for cashless treatment, where the insurer or its TPA pays the hospital directly. Anywhere else, or if cashless is not approved, you pay the hospital and claim reimbursement.

Both routes depend on the policy being in force, the treatment being covered and the waiting periods having ended. The insurer decides each claim against the policy wording.

Last reviewed on 18 October 2026. Exact requirements depend on your policy, the insurer and the rules in force.

Who this guide is for

  • People with individual, family floater or group (employer) health policies
  • Planned admissions and emergencies

Step by step

  1. Check that the policy is active and the hospital is in the insurer's network if you want cashless treatment.
  2. Inform the insurer or TPA: before a planned admission, or as soon as possible after an emergency admission, within the time the policy states.
  3. For cashless, the hospital sends the pre-authorisation request; for reimbursement, keep every original bill and report.
  4. At discharge, check the final bill against the approval and pay any part not covered.
  5. For reimbursement, submit the claim form and documents within the time limit in the policy.
  6. Read the settlement letter: it lists every deduction and the clause behind it.

Documents commonly asked for

DocumentWhy it is needed
Health insurance card or policy numberIdentifies the policy and the insured person.
Photo identity of the patientConfirms the patient is the insured person.
Doctor's advice for admission and treatment papersShows why hospital treatment was needed.
Bills, receipts, discharge summary and reports (for reimbursement)Show what was spent and on what treatment.

The insurer may ask for fewer or other documents depending on the case.

Common mistakes

  • Informing the insurer late without a reason you can explain
  • Not disclosing an existing illness when buying the policy
  • Choosing a room above the room-rent limit without knowing that other charges may be reduced in proportion
  • Throwing away original bills and pharmacy receipts

What the rules say

  • The insurer is to decide on a cashless request within one hour, and give final discharge approval within three hours of the hospital's request. [1]
  • For cashless claims, the insurer or TPA collects the documents from the hospital; the policyholder is not required to submit them. [1]

Rules referred to

  1. IRDAI Master Circular on Health Insurance Business (Insurance Products Regulations, 2024) (IRDAI/HLT/CIR/PRO/84/5/2024, 29 May 2024)
    Free-look period, grace period, moratorium period, cashless and discharge timelines.

Finobazaar read published copies of these rules on 19 October 2026. Rules change: check the current text on irdai.gov.in or with your insurer.

Important limitations

  • Time limits for informing the insurer and submitting documents differ between policies.
  • Group policies from employers can have their own rules.
  • This guide explains the usual process; it does not replace your policy wording or the insurer's instructions.
  • Following these steps does not guarantee that a claim will be paid.

Official resources

Addresses checked on 19 October 2026.

Frequently asked questions

Should I choose cashless or reimbursement?

Cashless avoids paying the covered amount yourself, but it works only at network hospitals and after approval. Reimbursement works at any hospital the policy allows, but you pay first and claim later.

What if my claim is partly paid?

The settlement letter must say why each amount was deducted. If you disagree, write to the insurer's grievance team with the clause you rely on; the claim rejection guide explains the next steps.

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