Health insurance claim settlement time: how many days does the insurer have?

Under the 2024 master circulars, a health reimbursement claim is to be settled within fifteen days of submitting it. For cashless treatment, the insurer must decide a pre-authorisation request within an hour and give final discharge authorisation within three hours of the hospital's request. If a claim is not settled in time, interest at the bank rate plus 2 percent runs from the date the claim was intimated, and the insurer is to pay it without being asked. At least one current policy wording also shows a longer period counted from the last necessary document; the circular's fifteen days is the figure to quote.

The reimbursement rule is one sentence in the Master Circular on Protection of Policyholders' Interests: "Settlement of claims (other than cashless) shall be settled within fifteen days from submission of claim."^[2]

At discharge, "In no case, the policyholder shall be made to wait to be discharged". If final authorisation takes longer than three hours, any extra amount the hospital charges because of the delay is to be borne by the insurer from its shareholders' funds — not by you. That covers the delay charge only; it does not make an inadmissible claim payable.^[1]

The interest is "bank rate plus 2 percent", and the circular says the insurer is to pay it suo moto — on its own, without being asked. The bank rate is the Reserve Bank of India's rate on the first day of the financial year in which the claim fell due, so check that figure with RBI rather than relying on a number quoted anywhere else.^{[2, 3]}

Why you may see other numbers

The IRDAI (Protection of Policyholders' Interests) Regulations, 2017 were repealed by the 2024 regulations, and the 2024 master circular's figure for a reimbursement claim is fifteen days from submission. Longer periods you may see online, or in a policy wording, are not the circular's figure; quote the circular.^{[3, 2]}

A current wording can carry both. One New India Mediclaim wording says in clause 5.10 that claims "shall be settled within fifteen days from submission of claim", and in clause 5.21 that it will settle or reject "within thirty days of the receipt of the last 'necessary' document", or within 45 days where it investigates. Its sister Arogya Sanjeevani wording runs interest from the last necessary document, where the circular runs it from intimation. If your wording and the circular differ, quote the circular in your complaint and ask the insurer which one it applied.^{[4, 5]}

What to do when the time has passed

1. 1

   Write down your dates

   When you intimated the claim, when you submitted it, every document request and every reply. See answering document requests.

2. 2

   Ask for the status in writing

   Ask what, if anything, is outstanding, and when a decision will be made.

3. 3

   Complain to the grievance officer

   Say clearly that it is a complaint about delay. An insurer should resolve a complaint within 14 days.^[2]

4. 4

   Ask about the interest

   When the claim is paid, check whether interest for the delay was included and from which date. See interest on a delayed claim.^[2]

5. 5

   Escalate if needed

   Delay in settling a claim beyond the time in the regulations is a ground the Insurance Ombudsman can hear, once your written complaint has been rejected, answered unsatisfactorily or left unanswered for a month.^[6]

ClaimAssure is an independent private platform. It is not an insurer, IRDAI, Bima Bharosa or the Insurance Ombudsman, it never files anything on your behalf, and it cannot promise any outcome. What it does is read your documents and show you what they say.

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