Insurance claims, from the hospital desk to the Ombudsman
A claim turns on timing, documents and who you write to. Start from where you are: how a claim works, what to keep, the deadlines your insurer must meet, and what to do if it is rejected or cut.
1 hour
To decide a cashless request
IRDAI, 29 May 2024
15 days
To settle a health claim that isn't cashless
IRDAI, 2024
14 days
To resolve your grievance
IRDAI, 2024
Reviewed by the BimaHaq Insurance Grievance Desk — BimaHaq's in-house insurance-grievance team — specialists in IRDAI grievance redressal, the Insurance Ombudsman process, and policyholder rights in India. · Last reviewed 2026-10-06
Where are you right now?
A claim can go wrong at any point, and the next step depends on which one. The shade shows how far along you are.
- Before you claim
- While it is in process
- After the decision
- Taking it further
- Before you claim
You haven't filed yet
Most claim problems are seeded at filing — wrong forms, missing documents, disclosures handled badly. This is the cheapest moment to get it right.
- While it is in process
Filed, and waiting
Insurers run on regulated timelines. Knowing which clock applies to your claim — and when it breaches — is leverage.
- While it is in process
The insurer keeps asking for more
Endless document queries are often a delay in disguise. One complete, consolidated reply ends the loop — and starts a clock for the insurer.
- While it is in process
Survey or investigation underway
What you say to a surveyor or investigator shapes the outcome. Open investigations are judgment territory, not form-filling.
- After the decision
Rejected — the ground decides the remedy
A rejection for missing documents and a rejection for non-disclosure are different problems with different remedies. Name the ground first.
- After the decision
Paid less than the claim
Short-paid is not settled. Deductions have named grounds, and each ground can be tested — some survive scrutiny, many don't.
- After the decision
Closed without settlement
Closure is the insurer's word, not the end of your remedies. What reopening takes depends on why it was closed.
- Taking it further
Grievance filed, insurer unmoved
A grievance the insurer ignores is not the end of the ladder — it is the qualifying step for everything above it.
- Taking it further
Weighing the Ombudsman or a consumer case
The forum choice matters more than it looks — once one forum is seized of your matter, others can be foreclosed. Choose once, and well.
Cashless or reimbursement
Two ways to claim on a health policy. Use cashless where you can — and if it is refused at the desk, the claim is not over.
Cashless
The hospital and insurer settle between them
You pay only what the policy does not cover.
Use a hospital in your insurer's network
Cashless works at hospitals in your insurer's or TPA's network — the list is on their website or app. Check before a planned admission, not at the desk.
The hospital asks for pre-authorisation
Its insurance desk sends the request with your policy number or e-card and photo ID. For a planned admission, start this before you are admitted, as your policy requires.
The insurer decides within one hour
IRDAI's Master Circular on Health Insurance Business (29 May 2024) requires a decision on a cashless request within one hour of receiving it.
Discharge authorised within three hours
Once the hospital asks for discharge authorisation, the insurer has three hours. If it takes longer, any extra amount the hospital charges for the delay is the insurer's to bear.
You pay only what the policy does not cover
Co-payment, deductibles and excluded items. Ask for the itemised bill and the insurer's settlement note before you pay the balance.
Reimbursement
You pay, then claim it back
Works at any hospital, and after a cashless refusal.
Tell the insurer or TPA about the admission
As your policy asks. Informing late is not, by itself, a reason the insurer may give for rejecting a claim (IRDAI, 2024).
Pay the hospital and keep every original
Bills, payment receipts, the discharge summary, reports and prescriptions — the documents list below is what the claim will need.
Submit the claim form with the documents
Within the time your policy allows. Keep a copy of everything you send and proof of when you sent it.
Answer any query in writing
A query is a request, not a rejection. Reply with what is asked, in writing, and keep the date.
Settlement within 15 days
IRDAI's Master Circular on Protection of Policyholders' Interests (2024) requires a claim that is not cashless to be settled within fifteen days of submission. If it is paid late, interest at the bank rate plus 2% is owed — added without your asking.
Cashless refused at the hospital? That is a decision at the desk, not a rejection of your claim — pay, keep every bill, and file for reimbursement.
Cashless denied: what to doDocuments to keep
What insurers commonly ask for. Your insurer's claim form names its exact set — if it does not, ask for the list in writing.
Health claim
- Claim form, filled in and signed
- Discharge summary
- Final hospital bill with the itemised break-up, and payment receipts
- Pharmacy bills with the prescriptions
- Investigation and test reports
- Doctor's consultation notes
- Photo ID and your policy or e-card
- Cancelled cheque or bank details, for a reimbursement
After an accident, add the FIR or medico-legal certificate if one was made.
Life (death) claim
- Claim form, filled in by the nominee
- Death certificate
- The policy document
- Nominee's photo ID, address proof and bank details
- Medical records and the treating doctor's certificate, if death followed an illness
If the death was unnatural, add the FIR, post-mortem report and police final report.
Motor (own damage) claim
- Claim form
- Registration certificate (RC)
- Driving licence of the person driving
- The policy
- Photos of the damage
- Repair estimate, then the final bill
For theft, or where police were involved, add the FIR. Let the insurer's surveyor see the vehicle before repairs begin, unless the insurer agrees otherwise in writing.
Keep one claim folder — every bill, report, letter and email, with its date, on paper and as a scan. A grievance, Bima Bharosa and the Ombudsman all ask for copies of what went before.
Deadlines your insurer must meet
IRDAI sets the clock, and it runs against the insurer, not you.
1 hour
To decide a cashless request
Health Master Circular, para 15(b)
3 hours
To authorise discharge
Health Master Circular, para 16
15 days
To settle a health claim that isn't cashless
Policyholders' Master Circular, 2024
Bank rate + 2%
Interest if it pays late
Added without asking
IRDAI Master Circular on Health Insurance Business (29 May 2024) and Master Circular on Protection of Policyholders’ Interests (5 September 2024).
Every claim clock, for health, life and motorFind the reason on your letter
Each guide sets out what the insurer has to prove, when the rejection does not hold, and the evidence to gather.
Health
8 guides
Motor and property
5 guides
Life and personal accident
3 guides
If the insurer says no, or says nothing
The route every insurer in India sits under, in order. The insurer, Bima Bharosa and the Ombudsman charge nothing to hear you.
- Get the rejection in writing from the insurerImmediately, before anything else
- Insurer's Grievance Redressal Officer (GRO)Step 1 of the formal ladder
- IRDAI via the Bima Bharosa portalIf the insurer doesn't resolve it within 14 days, or the reply is unsatisfactory
- Insurance OmbudsmanAfter the insurer rejects it, gives no reply for one month, or the reply is unsatisfactory
- Consumer Commission (e-Jagriti) or civil courtAs an alternative, or for any balance an Ombudsman award could not cover
Go to the Ombudsman before a consumer court, not after
Under Rule 14(5) of the Insurance Ombudsman Rules, 2017, the Ombudsman cannot take up a complaint on the same subject matter that is pending before — or has already been decided by — any court, consumer forum, or arbitrator. Filing a consumer case first closes the Ombudsman route for that dispute permanently, so approach the Ombudsman before the Consumer Commission, never after.
Find your insurer
The grievance officer’s email and postal address for 60 insurers, checked against each insurer’s own website — the first formal step.
Insurance Ombudsman offices
18 offices. Yours is the one covering where you live, or where the branch that handled your policy is — the PIN-code finder settles it.
Common questions
Is a cashless denial the same as a claim rejection?
No. A cashless denial is a preliminary decision at the hospital desk. You can still pay and claim reimbursement afterwards, and challenge the denial with the insurer — the claim is not finally decided by the TPA's cashless refusal.
How quickly must the insurer decide a cashless request?
Under IRDAI's Master Circular on Health Insurance Business (29 May 2024), the insurer must decide a cashless authorisation request within one hour of receiving it, and must give the final authorisation for discharge within three hours of the hospital's request. If it takes longer, any additional amount the hospital charges for the delay is the insurer's to pay, not yours.
How long can an insurer take to settle a claim?
Under IRDAI's 2024 Master Circular on Protection of Policyholders' Interests, a life death claim must be settled within 15 days of intimation (45 days if investigation is warranted) and a health reimbursement claim within 15 days of submission. For a motor or property claim the insurer must decide the claim “within seven days of receipt of the survey report or after expiry of fifteen days from allocation of the claim to the surveyor whichever is earlier” — the General Insurance Master Circular states it simply as seven days from the survey report — and that timeline does not apply to a property policy on a reinstatement-value basis.
What happens if the insurer is late?
It owes you interest at the bank rate plus 2%, calculated from the date it received intimation of the claim until the date it pays, and the circular says it must add this interest on its own (suo-moto). If it does not, ask for it in writing.
Can a claim be rejected because I was late or a document was missing?
No. The 2024 Master Circular expressly prohibits rejecting or closing a claim merely for want of documents or for delayed intimation; for health claims the insurer and TPA must themselves collect the required documents from the hospital.
My hospital discharge is being held up by the insurer. What are my rights?
For a cashless health claim the insurer must grant discharge authorisation within three hours of the hospital's request, and you must not be made to wait to be discharged. If it misses that window, any additional amount the hospital charges for the delay is borne by the insurer, not you.
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Sources
- IRDAI
- Bima Bharosa (IRDAI grievance portal)
- Council for Insurance Ombudsmen (CIO)
- e-Jagriti (consumer complaints)
- National Consumer Helpline (1915)
- CPGRAMS (Government of India grievance portal)
This guide is general information about the insurance-grievance process in India, not legal advice, and figures (timelines, monetary limits, jurisdiction) can change — verify against the official sources linked above before you rely on them.