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Start with your policy wording, submit the claim through the insurer’s stated cashless or reimbursement process, and keep dated proof of every document and message. If the insurer rejects, reduces, or delays the claim, demand a written reason tied to the exact policy clause. Then proceed in order: the insurer’s Grievance Redressal Officer (GRO), IRDAI’s Bima Bharosa grievance system, and, when the eligibility rules are met, the Insurance Ombudsman.
Approval is never automatic. Coverage depends on your policy schedule and wording, exclusions, waiting periods, limits, endorsements, disclosure history, medical records, and compliance with notice and documentation requirements. The procedures below help you protect your position; they do not determine whether a particular treatment is payable.
What governs a health-insurance claim?
Your insurance contract is the starting point. Read the policy schedule, policy wording, endorsements, health card instructions, claim form, and the insurer or third-party administrator (TPA) instructions that apply to the treatment. The contract may distinguish between cashless treatment at a network facility and reimbursement after you pay the provider. It may also prescribe notification, pre-authorisation, discharge, or document-submission steps.
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There is no single government checklist that fits every insurer and every claim. Before sending anything, ask the insurer or TPA for the current, claim-specific requirements and record the response. A missing item can be a genuine process problem, but the insurer should explain what is missing and how the request relates to the policy and claim.
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Cashless and reimbursement claims
- Cashless: The hospital or its insurance desk normally sends a pre-authorisation request to the insurer or TPA. Approval can be conditional, limited to eligible expenses, or refused. Keep the request, approval or refusal, final bill, discharge papers, and every query.
- Reimbursement: You pay the provider and submit the claim form and supporting records for assessment. Keep proof of payment and copies of the complete submission.
A practical working file
The following is a common-sense file, not an exhaustive legal or regulatory list. Gather the items that are relevant to your claim:
- Policy number, member or health-card details, and the policy schedule.
- Completed claim form and any pre-authorisation or notification reference.
- Hospital bills with itemised charges, receipts, and the final settlement statement.
- Discharge summary, prescriptions, consultation notes, and diagnostic reports.
- Pharmacy receipts and invoices linked to the treatment.
- Proof of payment for a reimbursement claim, such as receipts or bank records.
- Emails, letters, portal screenshots, call-reference numbers, and messages exchanged with the insurer or TPA.
Scan or photocopy everything before submission. Keep originals unless the insurer expressly requires an original and gives you a receipt. Name files consistently and maintain a simple chronology showing the date, sender, subject, and action taken.
How to file a health-insurance claim in India
1. Check coverage and the required route
Confirm that the policy was active on the relevant date and identify the applicable sum insured, sub-limits, co-payment, deductible, waiting periods, exclusions, and network-hospital rules. Check whether the treatment requires advance notification or pre-authorisation. If an emergency prevented advance notice, explain that fact promptly and ask how the policy handles emergency admissions.
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2. Notify the insurer or TPA
Use the contact channel named in your policy or health card. Ask for a claim or pre-authorisation number, the submission deadline stated in your policy, and the exact list of documents for this treatment. Write down the date and time, the representative’s name or reference, and any promised action.
3. Submit a complete claim
For cashless care, give the hospital insurance desk the policy and identification details and authorise it to send the medical records and estimate. For reimbursement, complete the insurer’s form accurately, attach the relevant bills and medical evidence, and include proof of payment. Do not alter invoices or submit duplicate claims without explaining any other coverage.
4. Obtain dated acknowledgement
Use a channel that produces evidence: an online receipt, email confirmation, courier delivery record, or a stamped submission copy. Save the claim number and the date the insurer says it received the last document. That date can matter if a delay dispute later concerns the time taken after the file became complete.
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5. Answer queries in writing
If the insurer asks for clarification or additional records, reply by the stated deadline and send only material relevant to the request. If a document does not exist, say so and explain why. Ask the insurer to identify the policy provision behind an unusual request. Keep proof that your reply was delivered.
6. Check the settlement statement
When the insurer pays, compare the approved amount with the bill, deductions, co-payment, deductible, sub-limits, non-payable items, and any explanation supplied. A partial settlement is not the same as a full rejection: challenge each disputed deduction separately and identify the amount involved.
What a rejection or partial settlement must tell you
IRDAI’s health-insurance FAQ states that, when a claim is denied or repudiated, the insurer must communicate the decision, specifically state the reasons, refer to the corresponding policy conditions, and provide grievance procedures. The official wording is: “Where a claim is denied or repudiated, the communication about the denial or the repudiation shall be made only by the Insurer by specifically stating the reasons for the denial or repudiation, while necessarily referring to the corresponding policy conditions.”
A hospital, broker, TPA or call-centre explanation is not a substitute for the insurer’s written decision. If you have only received a phone call or a generic portal status, request the formal letter or email. Ask for:
- The exact amount allowed, disallowed, or held back.
- The precise reason for every rejected or reduced item.
- The policy clause, exclusion, limit, waiting-period term, or endorsement relied on.
- The medical or billing document used to reach the decision.
- The insurer’s grievance procedure and complaint reference.
Match the reason to the evidence
Compare the decision with the policy schedule and wording, endorsements, claim form, medical records, itemised bills, and correspondence. Common categories that may require a focused response include a missing document, an exclusion, a waiting period, a pre-existing-condition provision, alleged non-disclosure, medical-necessity concerns, a non-payable item, or a policy limit. These are examples, not conclusions about your claim.
Make a table for your own file with four columns: disputed item, insurer’s reason, policy clause cited, and evidence that answers the reason. This prevents a broad emotional appeal from overlooking the particular deduction that controls the outcome.
Appeal first to the insurer’s Grievance Redressal Officer
The first formal appeal is a written complaint to the insurer’s Grievance Redressal Officer for the branch or office concerned. IRDAI directs policyholders to complain in writing, include supporting documents, and obtain an acknowledgement bearing the date. Send the complaint through the insurer’s published grievance channel and retain delivery proof.
Include these facts
- Policy number, claimant and patient details, and contact information.
- Claim or pre-authorisation reference number.
- Treatment, admission and discharge dates, hospital name, and the amount claimed.
- Amount paid, rejected, or deducted, if any.
- Date of the denial, repudiation, or settlement statement.
- The exact reason you dispute and the policy condition cited by the insurer.
- A short chronological account of notification, submission, queries, and responses.
- The remedy requested, such as reassessment, payment of a specified amount, correction of a calculation, or a clause-level explanation.
- An indexed list of attachments.
Attach and preserve
- The denial, repudiation, or settlement letter.
- Relevant policy pages and endorsements, not just the cover page.
- Claim forms, submission receipts, pre-authorisation records, and acknowledgement.
- Medical records and bills that address the disputed reason.
- Prior correspondence and replies to document requests.
Keep the originals and a complete copy of what you sent. Ask for a complaint reference and the date of receipt. The Bima Bharosa FAQ says the insurer should resolve a complaint within 15 days of receipt. Treat that as the stated grievance-resolution period, not as a promise that a claim will be paid.
A concise complaint structure
Use a descriptive subject such as “Grievance—claim [reference]—request for clause-based review.” Open with the policy and claim identifiers, state the decision and amount in dispute, quote or accurately paraphrase the insurer’s reason, identify the clause, explain the evidence that answers it, and state the remedy. End with an attachment index and a request for a dated written decision.
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Escalate through IRDAI’s Bima Bharosa
If the insurer’s reply is unsatisfactory, or the complaint is not resolved within the indicated period, use the IRDAI Bima Bharosa grievance route. The official FAQ lists an online portal, toll-free number 155255, email complaints@irdai.gov.in, and postal complaint options described on that FAQ.
What the portal does
A complaint registered through Bima Bharosa is routed to the insurer and recorded in the IRDAI repository. The FAQ says the system generates a trackable token number, mirrors status updates, and makes the insurer’s final resolution available in the complainant login. Save the token, screenshots, uploaded files, and every subsequent message.
Do not merge the different time statements
| Stage | Official timing statement | What the clock means |
|---|---|---|
| Insurer grievance | Resolve within 15 days of receipt, according to the Bima Bharosa FAQ. | Counts from the insurer’s receipt of your written grievance. |
| Bima Bharosa portal banner | “Your complaint will be attended to within 14 days.” | A portal service statement; it is not a guarantee of payment, adjudication, or a favourable outcome. |
| Bima Bharosa process page | Approach the Ombudsman if the complaint is not attended to within 15 days of registration or the insurer’s resolution is unsatisfactory. | Counts from Bima Bharosa registration for that escalation route. |
| Ombudsman information | No response from the insurer for 30 days is one listed condition after first approaching the insurer. | This is an Ombudsman eligibility condition and should not be treated as the deadline for every earlier step. |
These statements govern different stages. Keep the insurer acknowledgement date and the Bima Bharosa registration date separately. If a portal response arrives before the stated period but does not answer the disputed clause, describe why it is unsatisfactory rather than simply repeating the original claim.
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Protect yourself from Bima Bharosa scams
The current portal warns: “Bima Bharosa (IGMS) Portal does NOT ask for PAYMENTS OF ANY KIND from complainants/policyholders.” Do not pay someone who promises a faster resolution, scan a QR code to receive a payout, or follow an unsolicited link claiming to disburse money. Use only the official portal and contact channels, and verify any message independently through the insurer’s published details.
When the Insurance Ombudsman may be available
The Insurance Ombudsman is a further forum for an eligible individual policyholder after first approaching the insurer. IRDAI’s Ombudsman information lists rejection, an unsatisfactory resolution, or no response for 30 days among the conditions, and includes partial or total repudiation of health-insurance claims. It reports a ceiling of ₹30 lakh, including the expenses claimed.
Eligibility is not automatic. The filing must be connected to the Ombudsman with territorial jurisdiction, and current rules may specify filing windows, exclusions, documents, and an application method. Verify those requirements on the current IRDAI and Council for Insurance Ombudsman information before filing. The indexed IRDAI page used for these conditions was not directly accessible when reviewed, so do not rely on an old form or an undated copy.
Prepare an Ombudsman file
- Policy schedule, wording, endorsements, and identity or policyholder proof.
- Claim form, hospital records, bills, payment proof, and the insurer’s decision.
- Your written GRO complaint, acknowledgement, and the insurer’s final response or proof of no response.
- Bima Bharosa token and status history, if you used that route.
- A concise statement of the dispute, amount sought, and remedy requested.
- A chronological index with page numbers so the decision-maker can locate each document.
Do not wait for a generic “30-day rule” without checking the applicable scheme. A rejection or an unsatisfactory resolution may trigger a route under the Ombudsman rules, while the no-response condition is separately described as 30 days after approaching the insurer.
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First determine whether the insurer says the file is incomplete. Ask it to identify the last necessary document and the date received. If records are still outstanding, submit them promptly and retain proof. If the insurer is investigating, ask for the reason, expected next step, and the policy or regulatory basis for the delay.
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Choose the right forum in sequence
| Forum | Who handles it | When to use it | Role and evidence |
|---|---|---|---|
| Insurer GRO | The insurer’s grievance officer | Immediately after a rejection, reduction, delay, or unresolved service issue. | Requests internal reconsideration or a clause-based explanation; include the full claim file and dated acknowledgement. |
| Bima Bharosa | IRDAI grievance system routing the issue to the insurer and repository | After an unsatisfactory insurer response or when the stated insurer period has passed. | Regulatory grievance facilitation and tracking; preserve the token and portal history. |
| Insurance Ombudsman | The Ombudsman with territorial jurisdiction | After first approaching the insurer and meeting the applicable rejection, unsatisfactory-resolution, no-response, individual-policyholder, and value conditions. | Eligible dispute redress; verify current rules, filing window, jurisdiction, and the ₹30 lakh ceiling before filing. |
These are sequential forums, not interchangeable customer-service options. A Bima Bharosa token does not replace the insurer’s written decision, and an Ombudsman application does not remove the need to prove the policy, claim, amount, and prior complaint history.
Common mistakes and how to correct them
Relying on a phone refusal
Request a formal insurer communication stating the reason, policy condition, and grievance procedure. Record the call reference, but do not treat it as the final decision.
Sending an emotional, unfocused appeal
Use one section per disputed deduction. Link each section to a policy clause and an attachment. Ask for a specific remedy and amount.
Submitting originals without proof
Retain scans or copies and obtain a dated acknowledgement for anything delivered physically.
Missing the insurer’s document request
Reply before the stated deadline. If a document is unavailable, explain why and offer an alternative record rather than remaining silent.
Assuming every timeline starts on the admission date
For grievance and escalation purposes, the relevant date may be the insurer’s receipt of your complaint, the Bima Bharosa registration date, or receipt of the last necessary claim document. Track each separately.
Paying a “processing” intermediary
Official Bima Bharosa says it does not ask complainants or policyholders for payments. Stop communicating through suspicious links or QR codes and use verified official channels.
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- Do you have the policy schedule, wording, endorsements, and claim reference?
- Have you obtained the insurer’s written reason and the exact policy condition cited?
- Have you separated each rejected or reduced item and calculated the amount in dispute?
- Did you send a written GRO complaint with supporting documents and keep dated acknowledgement?
- Have you recorded the insurer receipt date and the date of the last necessary claim document?
- If using Bima Bharosa, did you save the token, uploads, status updates, and final resolution?
- Before approaching the Ombudsman, did you verify current jurisdiction, filing window, eligibility, procedure, and the ₹30 lakh claim-value ceiling?
- Have you kept originals, delivery proof, and a complete chronological index?
The strongest appeal is specific: it identifies the disputed amount, answers the insurer’s stated reason with evidence, cites the relevant policy wording, and asks the correct forum for a defined remedy. Follow the forum sequence and confirm current official rules whenever a deadline, interest calculation, or Ombudsman filing decision depends on them.
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