Health insurance claims
Health claims go wrong in a few recurring ways: a rejection that relies on a clause, a cashless request refused or approved for less than the bill, a wait at discharge, or a reimbursement that is cut or slow. Each has its own rules and its own documents, and the pages below take them one at a time.
Two rules from IRDAI's health master circular apply to all of them. A health claim cannot be rejected without the approval of the insurer's Product Management Committee or its Claims Review Committee, and a full or partial rejection must give details with reference to the specific terms of your policy.[1]
If the patient is a senior citizen, insurers must also run a separate channel for senior citizens' health claims and grievances, with its details on their websites.[2]
- Rejected because of an earlier illness: Check a pre-existing disease rejection or answer a non-disclosure allegation.
- Rejected under a clause: Waiting periods, exclusions, medical necessity and short hospital stays.
- Problems at the hospital: Cashless approved for less than the bill, a delayed discharge and non-network hospitals.
- Filing and following up: Reimbursement claims, lateness grounds and claim investigations.
- Who decides, and under which policy: Claims handled by a TPA, employer group policies and holding two policies.
- Particular kinds of cover: Pre- and post-hospitalisation bills, maternity, mental illness, critical illness and a lapsed or late-renewed policy.
Start here
- Health insurance claim rejected — how to read it and what to checkPre-existing disease, waiting periods, room-rent limits and sub-limits: grounds a health insurer may rely on to reject or cut a claim, and how to check each against your policy.
- Claim rejected for pre-existing disease (PED) — how do I check if the insurer is right?Test a PED rejection against your own dates: the 36-month definition, the waiting period, continuous cover and porting credit, and what to send the insurer.
- Cashless approved, but the hospital says I must pay the difference — why?Why cashless approval can fall short of the bill: non-payable items, sub-limits, room-rent limits, co-payment and final authorisation, and what to ask.
- How to file a health insurance reimbursement claim after paying the hospital yourselfA step-by-step health reimbursement claim: notice, documents, deadlines, proof of sending, the 15-day settlement rule and interest if the insurer is late.
- Discharge delayed while waiting for the insurer's final approval — what are the rules?IRDAI's rule on final authorisation at discharge: three hours from the hospital's request, who bears extra charges after that, and what to note meanwhile.
Questions people ask
- Your insurance claim was rejected. Here's what to do next.What a rejection letter actually means, how to check the insurer's reason against your own policy, and the steps open to you in India — explained plainly.
- Cashless request refused at the hospital — what it meansA denied pre-authorisation is not the same as a rejected claim. What to do at the hospital desk, what to collect before you leave, and how to claim reimbursement afterwards.
- Health claim rejected for non-disclosure — what if I wasn't asked, or didn't know?Answer a non-disclosure rejection: get the proposal form, test the question that was asked, check the 60-month moratorium, and respond to any cancellation.
- Claim rejected because of the waiting period — which waiting period applies to me?Initial, specific or PED waiting period? Tell which one the insurer used, check your policy's list, count continuous cover and use the accident exception.
- Claim rejected under a policy exclusion — how to read the exclusion clause properlyTest a rejection under an exclusion: read its exceptions and defined terms, look for benefits that cover the treatment, and hold the insurer to the wording.
- Insurer says the hospitalisation was 'not medically necessary' — how do I answer that?Answering a 'not medically necessary' rejection: the policy definition, its four tests, the evidence for each, and what the doctor's letter should say.
- Claim rejected because I was in hospital less than 24 hours, or it 'could be done in OPD'Rejected for a stay under 24 hours or as OPD care? Check the day care list, the hospitalisation and hospital definitions, and the times in hospital records.
- Health claim rejected for late intimation or late submission of documentsAnswer a late intimation or late documents rejection: what IRDAI's master circular says, what your policy's deadlines mean, and how to set out the dates.
- The TPA rejected my claim — is it the TPA's decision or the insurer's?A TPA processes claims for your insurer, but the insurer decides. Who approves a rejection, where to complain, and what to ask when a TPA sent the letter.
- Can I get cashless treatment at a hospital that isn't in my insurer's network?Does cashless work outside your insurer's network? What IRDAI requires insurers to publish, what is only an aim, and how to plan a reimbursement claim.
- Pre- and post-hospitalisation expenses not paid — how do I claim them?How pre- and post-hospitalisation cover works, why these bills get refused (window, condition, main claim), and how to claim them with the right papers.
- Maternity claim rejected — waiting period, sub-limit or 'not covered'?Why a maternity claim was rejected: no maternity cover, a waiting period, a sub-limit or newborn terms, and how to find the clause and its exceptions.
- Is mental illness treatment covered by health insurance — and what if the claim is refused?The Mental Healthcare Act requires mental illness cover on the same basis as physical illness. How to check a refused psychiatric claim and where to raise it.
- Employer group health insurance claim rejected — who do I complain to?Rejected under your employer's group health policy? Who decides, a rule that protects new joiners, and where to complain, from the insurer to the Ombudsman.
- I have two health policies — which one should I claim from first?With two health policies you pick the primary insurer, which must coordinate the balance. How indemnity and benefit policies differ, and the second claim.
- Critical illness claim rejected because the diagnosis 'doesn't meet the definition'A critical illness policy pays only when the diagnosis meets its definition. Check each criterion against your reports, plus waiting and survival terms.
- Claim rejected because my policy had lapsed or the renewal was late (grace period)Health claim refused because the renewal was late? The 15 and 30-day grace periods, when cover runs in them, what a break in policy means, and what to check.
Step-by-step guides
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Sources
The official documents this page relies on. Rules change: where it matters to your claim, check the current version at the source.
1. IRDAI (verbatim copy hosted by the Institute of Actuaries of India)
Master Circular on Health Insurance Business, Ref IRDAI/HLT/CIR/PRO/84/5/2024 dated 29.05.2024 (17 pages, Version 1)Dated 2024-05-29 · Accessed 2026-10-09 · Cited at: IRDAI Master Circular on Health Insurance Business (IRDAI/HLT/CIR/PRO/84/5/2024, 29 May 2024), Chapter I, para 17(a); IRDAI Master Circular on Health Insurance Business (IRDAI/HLT/CIR/PRO/84/5/2024, 29 May 2024), Chapter I, para 17(b)
Read from a copy hosted at actuariesindia.org · Official page
2. Gazette of India (Extraordinary, Part III Sec 4), hosted by Department of Financial Services, Ministry of Finance
IRDAI (Insurance Products) Regulations, 2024, F. No. IRDAI/Reg/8/202/2024, Hyderabad, 20 March 2024Accessed 2026-10-09 · Cited at: IRDAI (Insurance Products) Regulations, 2024, Schedule III, clause 11
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