Health Insurance Claim Process in India (2025): Step-by-Step Guide for Cashless & Reimbursement Claims

Making a health insurance claim can feel like a lot - lots of steps, lots of paperwork, and lots of fine print. But understanding how it works makes the whole thing much less stressful. In this guide, we’ll walk through what to expect, how to avoid common mistakes, and what you can do to make sure your claim goes through without unnecessary deductions or rejections.

First, let’s know how you’re going to make a claim. There are two ways to go about it:

➔ Cashless Claim (Handled through the Hospital)

This is usually the smoother option. You don’t have to pay anything upfront (unless something is not covered), and you skip a lot of the paperwork. But you may still need to follow up with both the hospital and the insurer while treatment is ongoing.

Just remember one thing: the hospital needs to be on your insurer’s list of approved "cashless" hospitals. If it’s not in the list of its network providers, this option won’t be available.

➔ Reimbursement Claim (Submitted Directly to your Insurer)

Here, you pay the hospital bill yourself, then apply for a reimbursement from your insurance company. You’ll have to collect and submit all the required documents, and the process usually takes more time. This type of claim is common if the hospital isn't tied up with your insurer’s network.

Health Insurance Claim Settlement Process

Now, let’s get into how the claim process usually works. Here’s how it typically goes when someone needs to be hospitalized:

Step 1

Choose a Hospital

In most cases, people prefer going to a hospital their doctor recommends, especially if the doctor practices there. If you can choose between a few, check your insurer’s website for the most recent list of cashless hospitals. That gives you the option to go cashless instead of paying upfront.

Step 2

Pick the Right Room Category

Health insurance often comes with a limit on how much room rent is covered. It might be a fixed amount or limited to a certain type of room. This is why you should try to pick a room within that range.

Ask the hospital for a rough cost estimate, including room charges. Then check your policy to see what kind of room rent is covered. If you go above your limit (like picking a deluxe room instead of a standard one), the insurance company may not just charge you the extra room rent, they might also reduce their share of other expenses. And yes, this can add up quickly.

If you have more than one policy, see if one of them doesn’t have a room rent cap. That could make a difference in how much you’ll get reimbursed.

Once you've picked the hospital and the type of room, the next step is handling the claim. This will either go through a cashless process or a reimbursement process. Here's how both work, in plain language.

Cashless Claim Process

Here’s how the cashless claim process works:

Check with the Hospital Desk
Don’t assume the hospital has a cashless arrangement with your insurer. These tie-ups change often. So, it’s best to double-check before getting admitted. Some hospitals have different procedures depending on the type of insurance, say, a corporate group policy vs. a comprehensive one. Make sure to ask clearly about the specific and also carry a copy of your policy with you. That makes it easier for the hospital to confirm things on their end.

Also, ask for a document checklist. The hospital staff will tell you what you’ll need to submit to keep things moving smoothly.

One more thing: look at your policy to see if there are any sub-limits for certain illnesses or treatments. This will help you figure out in advance how much you might have to pay yourself.
Pre-Authorization (a.k.a. First Approval)
This is the first step where the hospital reaches out to the insurer on your behalf. They will send a request to your insurance company for initial approval of your treatment costs. But for that to happen, you’ll need to tell the hospital’s insurance desk what policy you have and give them the documents they ask for.

You’ll also be asked to fill out a claims form. A section of it needs to be filled in by the hospital or your doctor. Once that’s done, the hospital takes over and sends everything to the TPA or your insurance provider for approval.
Paying an Advance (Even in Cashless Claims)
Here’s something most people don’t expect: even if you’re going the cashless route, you might still have to pay a small advance or deposit. Why? Because while insurance companies are often available round the clock, the hospital’s insurance desk usually works fixed hours. Most of them shut by 7 PM and are closed on Sundays. So, if you’re getting admitted late in the evening or on a weekend, you might have to pay upfront and wait for approval later.

Some hospitals also ask for a deposit even if cashless is approved as a backup. So always keep a little emergency cash or an active credit card with you. If the treatment can’t wait and there’s no time for pre-approval, you’ll likely be asked to pay first. That amount is usually refunded (fully or partially) once your insurer clears the claim.
Documents You Will Need
Before or during admission, make sure you’ve got these things on hand:
1. A copy of your insurance policy or the cashless card.
2. All medical reports and records related to the illness or injury.
3. KYC documents for the patient (usually ID proof and address proof).
4. If it’s due to an accident, you’ll also need the police FIR.
Things to Stay on Top of during a Cashless Claim
1. Handle Documentation Early
  If the hospital stay is planned, try to submit your pre-authorization form 3 to 4 days before you get admitted. That gives enough time for approvals to come through. If it’s a last-minute admission, reach the hospital at least an hour before. That way, you can complete the formalities without slowing things down. And if you’re the one getting admitted, ask a family member to go ahead and take care of the paperwork for you.
  
  For emergency cases, submit the form within 24 hours of getting admitted. Don’t delay it as cashless claims can get denied if the insurer doesn’t get notified in time.
1. Track the Approval Process
  After submitting the form, you can usually check the status on the TPA app or the insurance company’s website. Keep an eye on it. If the insurer asks for more documents or has questions, respond quickly. If there’s too much delay in replying, they can cancel the approval and then you will have to pay and file for reimbursement instead.
1. Keep a Copy of Everything
  You may need to hand over original bills or reports. So, before you do that, take clear photos or photocopies of each document. Once they’re submitted, it’s tough to get a second copy from the hospital.
1. Monitor Hospital Bills Daily
  Ask for the updated bill every day. This is because small errors in billing can easily go unnoticed if you wait until discharge. If you track charges daily, it’s easier to correct mistakes and update your insurer if the total cost goes up. Also, if one policy won’t be enough, you’ll have time to plan the use of another one.
1. Save all Pre-hospitalization Expense Records
  Costs before the hospital admission like tests, doctor visits, or medications aren’t part of the cashless claim. These need to be claimed separately later. Hence, keep all original prescriptions, reports, bills, and even scan reports. Start from the very first doctor you saw, especially if they’re not at the same hospital or aren’t your usual doctor.
1. Prefer Buying Medicines from the Hospital Pharmacy
  When it’s time for discharge, buy the prescribed medicines from the hospital’s pharmacy. That way, those expenses will also be included under cashless coverage. If you buy them from an outside store, they might not be covered.
Final Billing
Once your doctor confirms the discharge date, head to the hospital’s insurance desk and check the final paperwork. This includes the discharge summary, final bill, and any other required documents that need to go to the insurance company. The earlier you start, the smoother it’ll go.

After everything is submitted, the insurer may ask for additional documents. If that happens, they’ll usually notify you. Keep checking the insurer’s website or app to stay updated. If anything’s missing, send it in quickly to avoid delays.

Your claim won’t be fully processed until the final approval comes through. It normally takes around 2 to 6 hours after all documents are in, but sometimes it can be slower. If there’s a delay, the patient might have to wait longer in the hospital or you may be asked to pay upfront and later claim it back through reimbursement. Thus, just be mentally prepared for either.
Claim Approval
You will get a document from the insurer called a claim settlement summary. It breaks down everything: what was approved, what wasn’t, and why. Go through it carefully. If something wasn’t covered, it will be mentioned clearly (could be due to co-pay, proportionate deduction, or non-payable items like consumables). Remember that you will need to settle any amount not covered by insurance before discharge.

If you paid any advance earlier, make sure that amount is adjusted in the final billing. Some hospitals might also hold back a small deposit after discharge. This is a standard procedure and they keep it until the insurer settles the bill on their end. Also, don’t lose any receipts and set a reminder to follow up in a month or two to get that money back.

If your claim was partially paid because your sum insured was used up or due to other limits like exclusions or co-pay clauses, you might be able to claim the leftover amount under another insurance policy, through reimbursement.

And don’t forget: every cashless claim still has a reimbursement part for pre- and post-hospitalization expenses. Those aren’t included in the cashless approval, so you’ll need to file a separate claim for them. Keep all the prescriptions, test reports, and bills as you will need them.

Reimbursement Claim Process

Even though reimbursement claims are made after treatment and discharge, it’s important to keep a few things in mind before and during the hospital stay too. Reimbursement can apply in a few different situations:

It could be for the entire treatment including pre-hospitalization, hospital stay, and post-hospitalization care.
If you've already gone through a cashless claim, reimbursement usually covers the pre- and post-hospitalization expenses, since those aren't covered under cashless.

You can also use another policy to claim leftover expenses that weren’t covered in the first one, through reimbursement.

Inform the Insurance Company Early

The first step is called claim intimation or registration. Basically, you're letting your insurance provider know that a claim will be made. Try to do this within 24 hours of hospital admission, either by phone or email. The sooner, the better.

Ask them how much time you’ll have after discharge to submit the documents for the reimbursement claim; this way you don’t miss any deadlines. Also, request a detailed checklist
of documents you’ll need. Start collecting these right away so you’re not rushing around later.
Collect and Store all your Documents
Reimbursement depends almost entirely on the documents you submit. If you miss out on documents, there is a good chance your claim will get delayed or reduced. Start saving everything from day one - the first doctor visit, test reports, prescriptions, bills, and even scans or X-ray films. Keep them all together in one place.
Make sure you also collect:
1. Consultation notes
2. Lab reports
3. Pharmacy bills
4. Hospital invoices
5. Discharge summary
6. Post-discharge prescriptions and follow-up bills
A good idea is to create a simple Excel sheet to track all your medical expenses. Log each bill, receipt, and test in the order they happened. Number each document and keep them in a folder (physical or digital) so it’s easier when you submit everything. When you fill out the claim form, read it carefully. Fill in every field properly and check the details twice, small mistakes can cause delays.

Documents You’ll Need for a Reimbursement Claim
Here’s a list of what you’ll need to submit when filing a reimbursement claim. Make sure everything is ready and properly arranged before you send it across:
1. Health card or a copy of your policy
2. Photo ID of the insured person
3. The claim form, duly filled and signed. (Part of it needs to be filled out by the hospital and signed by the treating doctor)
4. Prescriptions for all medicines and tests, including the very first one that led to this hospitalization. Keep those originals safe, especially if they came from a doctor outside the hospital or from a clinic not linked to your regular care.
5. All pharmacy bills in original
6. All test reports, including films and CDs like X-rays or MRIs, in original
7. Hospital bill with the patient’s details and a proper itemized breakdown, in original
8. Discharge summary from the hospital, again in original
9. Any other original bills from before your hospital admission that are related to your treatment. (Bills for post-hospitalization expenses can be claimed separately, usually within 60 days and so, check your policy to confirm the time frame)
10. Bank account details of the policyholder. You will need to give a cancelled cheque so they can do an NEFT transfer. Insurance companies don’t issue cheques anymore as everything is done online.
11. If your hospitalization was due to an accident, the insurance company may ask for an FIR, medico-legal certificate, or a short note explaining what happened.
Keep a Copy of Everything
Before submitting your documents, make sure you keep a copy of each one, either photocopies or scanned versions. Once originals are submitted, you probably won’t get them back, so it’s better to have backups for your own record.
Stay on Top of Queries
Sometimes the insurer may raise questions or ask for more paperwork. Track your claim status regularly using the insurer’s app or website. If they’ve asked for anything, respond as soon as you can. Delays in replying could slow down the settlement process.
Claim Settlement
Once the claim is processed, the insurer will credit the approved amount directly into the bank account you provided. You’ll also get a claim settlement summary explaining what’s been approved and what was deducted. Take time to go through this summary. It’s important to understand what wasn’t covered and why.

If anything seems unclear or if you disagree with any deduction, you can reach out to the insurer and ask for an explanation or raise a formal query.

Wrapping Up

This list pulls together everything we know about the cashless and reimbursement claim process – what works, what causes delays, and how to make sure things go smoothly.

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