Cashless claim process in India, step by step, with IRDAI time limits

How cashless works

In a cashless claim, you do not pay the covered part of the bill. The hospital's insurance desk asks your insurer, or the TPA acting for it, to approve the treatment. The insurer then pays the hospital directly, up to the amount it approved. You pay only what the policy does not cover.

IRDAI's Master Circular of 29 May 2024 says every insurer "shall strive to achieve 100% cashless claim settlement", with reimbursement only in exceptional cases.

Before admission

• Check that the hospital is in your insurer's network. The insurer must list its cashless hospitals on its website, and a TPA must disclose the hospitals it has agreements with.
• Keep your policy number, the insurance ID card or e-card and a photo ID ready.
• Tell the insurer or TPA about the admission. Your policy sets the notice period. The standard wording IRDAI published in 2020 asks for notice at least 48 hours before a planned admission, and within 24 hours of an emergency admission.

Step by step

1. The insurance desk fills the cashless request form with the doctor's diagnosis, planned treatment and a cost estimate. You sign the patient declaration on it.
2. The desk sends the request to the insurer or TPA.
3. The insurer decides within one hour of receiving it. 1 h
4. The hospital gets an authorisation letter stating the amount approved.
5. If the cost rises during the stay, the hospital sends an enhancement request.
6. At discharge, the hospital sends the final bill and discharge summary for final approval.
7. The insurer gives final authorisation within three hours. 3 h
8. You pay for non-payable items, any co-payment or deductible, and anything above your limits. You sign the final bill and go home.

The IRDAI time limits

• 1 hour decision on the cashless request
• 3 hours final authorisation for discharge

Insurers had until 31 July 2024 to put the systems for the one-hour rule in place. The same circular says insurers must also give pre-authorisation to the policyholder in digital form, and may run help desks inside hospitals.

When the limits are missed

For discharge, the circular spells out the consequence. If the insurer takes longer than three hours, any additional amount the hospital charges must be borne by the insurer "from shareholder's fund". The circular adds that the policyholder shall not be made to wait to be discharged.

For the one-hour decision, the circular names no separate penalty. The clock starts when the insurer receives the request, so ask the desk what time it sent the request and whether the insurer asked for anything more.

If either limit is missed, write to the insurer's grievance officer with the times. You can also register the complaint on IRDAI's Bima Bharosa portal. If a claim is paid late, the September 2024 policyholder master circular says the insurer must pay interest at bank rate plus 2% on its own.

If cashless is refused

If cashless is refused, the hospital can still treat you. IRDAI's 2020 cashless admission procedure for hospitals says so, and adds that emergency care cannot be held back while the hospital waits for approval. You can pay and then file a reimbursement claim.

Under the 2024 rules, the insurer's Product Management Committee, or its three-member Claims Review Committee, must approve every rejection. Any rejection or partial cut must be explained in writing with reference to the specific policy terms. A TPA cannot reject a claim on its own.

Have a hospital stay coming up? Send your policy on WhatsApp and a person checks it for you.