Health & claims
How do I make a health insurance claim?
Tell the insurer or its TPA as early as you can, then claim either cashless, where the insurer pays a network hospital directly, or by reimbursement, where you pay and claim back. Under IRDAI’s 2024 rules, a cashless request must be decided within one hour, and a claim must be settled within 30 days of the last necessary document.
In short
- Inform the insurer early, before a planned admission or soon after an emergency.
- Cashless at network hospitals; reimbursement anywhere the policy allows.
- Insurers must decide cashless in one hour and settle within 30 days of the last document.
- Keep your own copies of every bill and the discharge summary.
Step 1: Tell the insurer early
Inform the insurer or its TPA before a planned admission, or as soon as possible after an emergency one. Have your health card or e-card and policy number ready. Early notice is what makes cashless possible and avoids disputes later.
Step 2: Cashless or reimbursement
| Cashless | Reimbursement | |
|---|---|---|
| Where | A network hospital | Any hospital the policy allows |
| Who pays the hospital | The insurer, directly | You, first |
| The rule that applies | Decision within 1 hour; discharge approval within 3 hours | Settlement within 30 days of the last necessary document |
Our page on cashless vs reimbursement explains both in detail.
Step 3: Documents
Under IRDAI’s May 2024 master circular, insurers and TPAs are to collect the documents they need from the hospital, rather than burden you with them. Still keep your own copies of the discharge summary, every bill and receipt, prescriptions and test reports. If you claim by reimbursement, you will usually submit these yourself.
Step 4: If the claim is delayed or cut
Delays carry interest, and rejections can be challenged. If the insurer investigates, it must settle within 45 days of the last document, and late payment carries interest above the bank rate. If a claim is cut or rejected, ask for the reason in writing; escalate to the insurer’s grievance officer, then Bima Bharosa, then the Insurance Ombudsman.
What if I have more than one health policy?
You can choose which policy to claim on first. The 2024 rules let you pick the primary policy; any balance can then be claimed from the other, within each policy’s terms.
Frequently asked questions
How do I claim health insurance?
Inform the insurer or TPA early, then claim cashless at a network hospital or pay and claim reimbursement. Keep copies of all bills and the discharge summary.
How long does a health insurance claim take?
A cashless request must be decided within one hour. A claim must be settled within 30 days of the last necessary document, or 45 days if investigated.
Do I have to submit documents for a health claim?
Under IRDAI's 2024 rules, insurers and TPAs are to collect the documents from the hospital. For reimbursement claims you will usually submit them yourself.
What happens when you talk to us
A 20-minute video call with a Growth Advisor. No obligation, and no quote pushed. It opens with a five-minute video from our founder on how the benefits stack works and why Ethika exists; the rest is your questions. You’ll leave with an honest read on your current cover and claims experience, and a straight answer on whether we can genuinely help, even if you never become a client.
20 minutes with a Growth Advisor. No obligation.
A note on this page. Everything here is general information, not legal advice, and nothing is an offer. Timelines are per IRDAI’s Master Circular on Health Insurance Products, 29 May 2024, and the related policyholder-protection rules, at the review date. For help with your situation, talk to us.