Health Insurance Claim Process — Complete, Practical Guide
Everything you need about making successful health insurance claims: cashless, reimbursement, documentation, timelines, sample letters & checklists.
- Introduction & Why Claims Matter
- Types of Claims: Cashless vs Reimbursement
- Pre-claim Preparation — Documents & Steps
- Cashless Claim Process (Step-by-step)
- Reimbursement Claim Process (Step-by-step)
- Timelines, SLAs & Escalation
- Common Reasons for Rejection & How to Avoid
- Special Cases: Maternity, AYUSH, Overseas
- Real-world Examples & Case Studies
- Templates: Forms, Letters, Checklists
- FAQ & Glossary
- Appendix & Resources
Tip: use browser Find (Ctrl/Cmd+F) to jump to any specific term in this long article.
Introduction & Why Claims Matter
Health insurance is purchased to transfer the financial risk of medical expenses. The policy is only as valuable as the claim process — the moment you need money for treatment, a smooth claim process reduces stress, avoids out-of-pocket shocks, and ensures timely medical attention.
What is a Claim?
A request to your insurer to reimburse medical expenses or settle them directly (cashless) as per the policy contract.
Why claims fail
- Incomplete documents or wrong details.
- Non-disclosure of pre-existing conditions.
- Policy exclusions (specific treatments not covered).
- Late intimation to insurer.
Quick tip: Keep digital copies of all medical bills and reports. Photo backups on cloud storage make claim submission faster and safer.
Types of Health Insurance Claims
1. Cashless Claims
Settled directly between insurer and network hospital. The insured pays only non-covered items (if any).
2. Reimbursement Claims
You pay the hospital first and later submit bills to insurer for refund per policy terms.
3. Pre-authorization
A required step for planned hospitalization or some treatments — insurer estimates coverage before treatment.
Comparison
| Feature | Cashless | Reimbursement |
|---|---|---|
| Who pays at hospital | Insurer (direct) | Insured (first), insurer later |
| Network required | Yes | No |
| Processing time | Usually faster | Depends on documents and verification |
Pre-Claim Preparation — Documents & Steps
Prepare the following before initiating a claim. Organize into a folder (physical & digital).
Master Document Checklist
- Policy document / Policy number & card
- ID proof (Aadhaar / PAN / Passport / Driving License)
- Hospital discharge summary
- All prescriptions & doctor notes
- Investigation reports (labs, imaging)
- Original bills & receipts (itemized)
- AR (admission & discharge) forms
- Medical practitioner’s certificate if required
- Cancelled cheque / bank details for reimbursement
- Any pre-authorization forms or network hospital forms
Best Practices
- Inform insurer immediately — many insurers require intimation within 24–48 hours for hospitalization.
- Collect the hospital’s itemized bill. Vague bills delay claims.
- Ensure all reports have patient name, date, and hospital letterhead.
- For cashless — request pre-authorization early and confirm network status.
Cashless Claim Process — Step-by-step
Cashless is the most convenient for hospitalized emergencies and planned surgeries at network hospitals. Below is a practical step-by-step flow.
Step 0 — Confirm Network Hospital
Confirm the hospital is in your insurer’s network via the insurer’s app, website or helpline.
Step 1 — Intimation & Pre-authorization
- Call insurer’s 24/7 claim helpline — give policy number, patient's name, hospital details and nature of ailment.
- Insurer issues a pre-authorization form if eligible. Hospital fills clinical details and submits to insurer.
Step 2 — Hospital & Insurer Assessment
Insurer reviews medical necessity, coverage and previous history. They may approve fully, approve partially, or ask for additional info.
Step 3 — Approval & Admission
On approval, insurer communicates limit and covered amount. Patient is admitted and treatment proceeds with insurer guaranteeing payment to hospital per approved amount.
Step 4 — Settlement
Post-treatment, hospital submits final bill to insurer and insurer settles directly with hospital.
Cashless Flow — Quick Checklist
- Keep policy number and ID ready.
- Call helpline within insurer-specified time.
- Submit pre-authorization & hospital forms.
- Follow up with insurer & hospital during treatment.
Reimbursement Claim Process — Step-by-step
When you pay first and claim later, accuracy and thorough documentation are essential.
Step 1 — Intimation
Inform insurer immediately (many insurers expect intimation soon after hospitalization). Some reimbursement claims require pre-authorization for planned admissions — check your policy.
Step 2 — Collect Documents
- All original bills (itemized) with dates & signatures
- Discharge summary with diagnosis and treatment details
- Doctor’s prescription & consultation notes
- Investigation reports
- Payment receipts and proof of payment (wallet/UPI/bank statement)
Step 3 — Fill Reimbursement Form
Most insurers provide a claim form — some accept online submission through portals/apps. Fill details accurately and attach supporting documents.
Step 4 — Submit & Track
Submit at insurer branch or upload through the insurer portal. Maintain copies.
Step 5 — Claim Assessment & Settlement
Insurer may request additional documents or clarification. After verification, they release payment to your bank account as per policy terms (less deductibles/exclusions).
Timelines, SLAs & How Long Claims Take
Timelines vary by insurer and whether claim is cashless or reimbursement. Below are typical timelines — check exact timelines in your policy and insurer guidelines.
| Activity | Typical Time | Notes |
|---|---|---|
| Claim intimation (emergency) | Within 24–48 hours | Delays can cause rejection |
| Pre-authorization response | Within 2–24 hours (urgent) | Depends on documents & hospital coordination |
| Reimbursement settlement after submission | 7–21 working days | Delays when documents incomplete |
Escalation Path
- Call helpline and get reference number.
- If unresolved, email grievance cell (contact details on insurer’s website).
- Escalate to insurer’s nodal officer / ombudsman (regulatory option if internal grievance fails).
Common Reasons for Claim Rejection & How to Avoid
Top Reasons
- Non-disclosure of pre-existing conditions at policy purchase.
- Late intimation to insurer for emergency hospitalization.
- Missing or incomplete documents (discharge summary, bills).
- Treatment falls under exclusions in policy.
- Claims for experimental or cosmetic procedures.
- Policy lapsed or premiums unpaid.
How to Avoid Rejection — Practical Steps
- Read policy exclusions carefully (list them down).
- Pay premiums on time — set an auto-pay or reminder.
- At purchase, declare all pre-existing conditions and past treatment history.
- Maintain neat, itemized bills and store originals safely.
- Follow insurer’s pre-authorization process for planned admissions.
If Rejected — Steps to Take
- Request a written rejection letter with reasons from the insurer.
- Review policy terms carefully and check if the reason is valid.
- Provide any additional documents requested and appeal internally.
- If unresolved, approach insurance ombudsman / regulator (e.g., IRDAI in India) — include all documents and timeline in the complaint.
Special Cases & Tips
Maternity Claims
Often have waiting periods (e.g., 2–4 years). Keep pre and post-natal documents, hospital bills, and birth certificate for newborn inclusion.
Critical Illnesses
Some policies have sub-limits or separate critical illness covers. Check definitions (e.g., what counts as “heart attack” under the policy).
AYUSH & Alternative Therapies
Many policies in India now cover AYUSH (Ayurveda, Yoga, Unani, Siddha, Homeopathy) in-network; confirm limits and documentation needed.
Pre-existing Conditions
Most insurers have waiting periods. If condition declared at purchase and waiting period served, future claims may be allowed.
Real-Life Case Studies (Summarized)
Case Study 1 — Emergency Cashless Success
Situation: Person A had a cardiac emergency and admitted to a network hospital. Pre-authorization was sought by hospital. Insurer approved within 2 hours and settled most expenses in cashless mode.
Key reasons for smooth claim: Policy active, hospital network, quick intimation and complete documents.
Case Study 2 — Reimbursement Rejection and Appeal
Situation: Person B paid for a specialized surgery then claimed reimbursement. Rejected due to missing discharge summary and lack of doctor's signature. After submitting the missing documents and an appeal, the claim was settled.
Lesson: Re-check every document before submission; keep original signed reports.
Templates & Downloadables
1. Reimbursement Claim Form (Sample — copy & paste into insurer form)
Policy Number:
Name of Insured:
Name of Patient:
Relationship:
Hospital Name & Address:
Admission Date:
Discharge Date:
Diagnosis:
Total Amount Claimed:
Bank Account Name:
Account Number:
IFSC:
List of attached documents: Discharge Summary, Bills, Receipts, Doctor Prescription, Investigations, ID Proof
Signature:
Date:
2. Sample Claim Intimation Email
To: claims@insurer.com
Subject: Claim Intimation — Policy [POLICY NO] — [Patient Name]
Dear Claims Team,
This is to inform you that [Patient Name] (Policy No: [POLICY NO]) was admitted to [Hospital Name] on [admission date] for [brief reason]. Kindly register this claim and advise pre-authorization / next steps. Hospital contact: [phone].
Attached: policy copy, ID proof, hospital admission record.
Regards,
[Name]
[Contact phone]
3. Sample Appeal Letter (if claim rejected)
Date:
To,
Grievance Redressal Officer,
[Insurer Name]
Subject: Appeal against claim rejection — Claim Ref: [Ref No]
Dear Sir/Madam,
I refer to your rejection letter dated [date]. I request reconsideration because [reason — e.g., documents submitted, medical necessity]. Attached are the missing documents and a physician statement confirming medical necessity.
Kindly review and settle the claim as per policy terms.
Regards,
[Name, policy number, contact]
4. Printable Claim Checklist (for hospital)
- ID proofs — copy & original
- Policy copy & card
- Hospital registration & admission note
- All itemized bills
- Discharge summary & doctor’s notes
- Doctor’s prescription & investigation reports
Frequently Asked Questions (FAQ)
How long does a reimbursement claim take?
Typically 7–21 working days after submission, subject to complete documentation. Complex or high-value claims may take longer due to investigation.
Can I change hospitals after pre-authorization?
Changing hospitals can invalidate pre-authorization. Always coordinate with insurer and hospital before transfer.
What if my policy was purchased recently and I need immediate treatment?
Check waiting periods and specific policy clauses. New policies often have waiting periods for certain treatments and pre-existing conditions.
How to escalate a delayed claim?
- Get claim reference number & escalate via email to grievance cell.
- If unresolved, contact the insurer’s nodal officer.
- If still unresolved, file with insurance ombudsman/regulatory grievance portal with documents and timeline.
Glossary
- Pre-authorization
- Insurer’s provisional approval before treatment.
- Co-pay
- Portion of claim amount that insured pays even for covered events.
- Sub-limit
- Maximum insurer limit for a particular expense (e.g., room rent).
Extended Case Studies — Real Scenarios & Lessons
Below are multiple real-world styled scenarios covering different claim types, outcomes, and lessons. These examples are for educational purposes and help policyholders anticipate possible situations.
Case Study 3 — Claim Denied for Cosmetic Surgery
Situation: Mr. Raj underwent a cosmetic nose surgery after an accident years ago. He claimed it under his health insurance policy.
Outcome: Claim denied — cosmetic surgeries without medical necessity are excluded.
Lesson: Check policy exclusions; cosmetic procedures are often excluded unless reconstructive and medically necessary after an accident within policy terms.
Case Study 4 — Partial Claim Approval due to Sub-limit
Situation: Ms. Anita was hospitalized for gallbladder surgery. Room rent chosen was ₹10,000/day; policy sub-limit was ₹5,000/day.
Outcome: Claim partially approved — other expenses were proportionately reduced due to higher room rent selection.
Lesson: Always match hospital room rent to policy sub-limits to avoid proportional deduction.
Case Study 5 — Overseas Emergency Claim
Situation: Mr. Iqbal fell ill in Singapore. He paid bills and filed reimbursement.
Outcome: Approved after 25 days, currency conversion rate as per RBI on discharge date was applied.
Lesson: Keep original bills, hospital records, passport entry/exit stamps; submit currency conversion proof if possible.
Case Study 6 — AYUSH Claim Approval
Situation: Ms. Priya took Ayurveda inpatient treatment at a NABH-accredited AYUSH hospital.
Outcome: Approved — policy covered AYUSH up to ₹50,000/year in network facilities.
Lesson: Confirm hospital accreditation before AYUSH claims; attach accreditation proof with claim documents.
Case Study 7 — Emergency Without Cashless Facility
Situation: Mr. Sunil’s accident admission was in a non-network hospital at midnight.
Outcome: Paid from pocket, later reimbursement approved after 3 weeks.
Lesson: Keep all bills, photos, and discharge documents. Intimate insurer immediately even if not cashless.
Case Study 8 — Claim Delayed Due to Missing Bank Details
Situation: Reimbursement claim stuck for 15 days.
Outcome: Delay due to missing cancelled cheque — insurer could not transfer amount.
Lesson: Always attach cancelled cheque or bank mandate form.
Case Study 9 — Maternity Claim Rejected due to Waiting Period
Situation: Couple claimed maternity expenses within 12 months of policy start.
Outcome: Rejected — policy had 2-year waiting period.
Lesson: Understand waiting periods before expecting coverage.
Case Study 10 — Claim Approved After Ombudsman Intervention
Situation: Claim rejected for “pre-existing condition not declared” despite insured having disclosed in proposal form.
Outcome: Ombudsman ordered approval after verifying proposal form copy.
Lesson: Keep a copy of your signed proposal form; it is proof of disclosure.
Case Study 11 — High-Value Cancer Treatment Claim
Situation: ₹15 lakh cashless claim for cancer therapy.
Outcome: Approved in parts, with 10% co-pay applied as per senior citizen policy clause.
Lesson: Large claims may be paid in tranches; understand co-pay clauses in advance.
Case Study 12 — Claim Rejection for Experimental Therapy
Situation: Patient underwent experimental stem cell therapy.
Outcome: Rejected — therapy not recognized under standard treatment guidelines.
Lesson: Coverage applies only to recognized, evidence-based treatments unless policy specifically includes experimental procedures.
Sample Claim Letters & Emails — 50+ Formats
Below are templates you can adapt for different claim scenarios. Replace placeholders with actual details.
1. Emergency Cashless Intimation Email
Subject: URGENT: Cashless Claim Intimation — [Policy No]
Dear Claims Team,
Patient [Name], Policy [No], admitted to [Hospital Name], [City], today at [Time] due to [Condition].
Please initiate cashless process. Pre-auth form attached.
Regards,
[Name], [Contact]
2. Planned Surgery Cashless Request
Subject: Planned Surgery — Cashless Approval Request — [Policy No]
Dear Claims Dept,
This is to request pre-authorization for planned [Surgery Name] on [Date] at [Network Hospital].
All required documents attached (doctor advice, reports, ID, policy copy).
Kindly confirm approval.
Regards,
[Name], [Contact]
3. Reimbursement Claim Submission Cover Letter
Date: [DD/MM/YYYY]
To,
Claims Dept, [Insurer Name]
Subject: Submission of Reimbursement Claim
Policy No: [No]
Please find enclosed reimbursement claim documents for hospitalization from [Date] to [Date] at [Hospital Name].
Documents enclosed: [List]
Kindly process as per policy.
Signature:
Name:
Legal & Regulatory Framework — Health Insurance Claims in India
The claim process in India is governed by the Insurance Regulatory and Development Authority of India (IRDAI). Every insurer must follow standardized timelines, disclosure norms, and grievance redressal protocols.
Key IRDAI Claim Regulations (as per latest circulars)
- Claim Intimation: For emergencies, inform the insurer within 24 hours. For planned hospitalization, inform at least 48–72 hours before admission.
- Claim Settlement Timelines:
- Cashless: Insurer to respond to pre-authorization within 2 hours (emergency) or 48 hours (planned).
- Reimbursement: Settlement or rejection within 30 days of receiving last required document.
- Interest on Delays: If insurer delays beyond timelines, they must pay interest at 2% above bank rate from date of receipt of last document.
- Reason for Rejection: Insurer must communicate in writing, citing policy clause and reason.
- Grievance Redressal: Every insurer must have a grievance officer, toll-free helpline, and email for complaints.
Grievance Redressal Escalation
- Level 1: Contact insurer's customer care — obtain complaint reference number.
- Level 2: Write to insurer's Grievance Redressal Officer with all claim details, copies of documents, and reference number.
- Level 3: If no response within 15 days or unsatisfactory reply, escalate to IRDAI via:
- IRDAI Grievance Management System (IGMS) portal: www.irdai.gov.in
- Email: complaints@irdai.gov.in
- Call: Toll-free 155255
- Level 4: Insurance Ombudsman — jurisdiction based on policyholder’s residence. No fee to file complaint.
Important Circular References
- IRDAI (Protection of Policyholders' Interests) Regulations, 2017
- IRDAI Health Insurance Regulations, 2016 (and amendments)
- IRDAI Circular on Settlement of Claims, 2020
Mega Glossary — 100+ Health Insurance Terms Explained
This glossary helps decode technical words found in policies and claim documents.
- Accident
- Sudden, unforeseen event causing injury.
- Aggregate Limit
- Maximum total claim payable in a policy year.
- AYUSH
- Ayurveda, Yoga, Unani, Siddha, Homeopathy — traditional medicine systems in India.
- Beneficiary
- Person entitled to receive benefits under the policy.
- Cashless Facility
- Direct settlement between insurer and network hospital without payment by insured.
- Claim Form
- Document used to request payment from insurer for covered expenses.
- Co-pay
- Portion of claim amount to be paid by policyholder, expressed as percentage.
- Day-care Procedure
- Treatment or surgery requiring less than 24-hour hospitalization.
- Deductible
- Amount policyholder must pay before insurer starts paying.
- Exclusions
- Events, treatments, or conditions not covered under policy.
- Free-look Period
- 15–30 days from policy receipt to review and cancel without penalty.
- Grace Period
- Extra time to pay premium after due date without losing coverage.
- IRDAI
- Insurance Regulatory and Development Authority of India.
- Loading
- Increase in premium due to higher risk factors.
- Network Hospital
- Hospital having tie-up with insurer for cashless treatment.
- No-claim Bonus
- Reward (discount or sum insured increase) for no claims in policy year.
- Ombudsman
- Independent authority resolving insurance disputes free of cost.
- Policy Schedule
- Document showing policy details, coverage, and conditions.
- Pre-existing Disease
- Illness or condition present before policy inception.
- Pre-authorization
- Insurer’s provisional approval before treatment.
- Proposal Form
- Application form filled at policy purchase with health & personal details.
- Room Rent Limit
- Maximum daily hospital room cost covered by insurer.
- Sum Insured
- Maximum amount payable in a policy year.
- Third Party Administrator (TPA)
- Entity handling claims on insurer’s behalf.
- Waiting Period
- Time after policy purchase before certain treatments are covered.
Common Mistakes in Health Insurance Claims & How to Fix Them
1. Late Intimation
Problem: Insurer informed days after hospitalization.
Solution: Inform within 24–48 hours; keep insurer helpline saved in phone.
2. Submitting Photocopies Instead of Originals
Problem: Originals required for reimbursement; photocopies cause rejection.
Solution: Submit originals, keep scanned copies for your records.
3. Missing Bank Details
Problem: Claim stuck due to missing account details.
Solution: Always attach cancelled cheque with claim form.
4. Wrong Policy Number
Problem: Data entry errors cause mismatches in claim registration.
Solution: Double-check before submission; write clearly.
5. Ignoring Sub-limits
Problem: Higher room rent triggers proportional deduction.
Solution: Match room selection to policy sub-limits.
State-wise & City-wise Tips for Maximizing Hospital Network Benefits
Choosing the right hospital in your insurer’s network can make or break your claim experience. Below is a state-by-state guide for India.
Delhi NCR
- Always check for hospitals in both Delhi and Gurgaon to maximize coverage.
- Preferred network: AIIMS (limited cashless), Fortis, Max, Medanta.
- Tip: In Delhi, many TPAs require prior appointment for planned cashless — book 72 hours before.
Maharashtra (Mumbai & Pune)
- Mumbai network hospitals often have special counters for cashless processing.
- Popular: Lilavati, Kokilaben, Breach Candy, Ruby Hall (Pune).
- Tip: For Pune, some network hospitals process claims faster than Mumbai branches due to lower patient load.
Karnataka (Bangalore)
- Preferred: Manipal, Narayana Hrudayalaya, Apollo Bannerghatta.
- Tip: Bangalore insurers often approve cashless in 2 hours if admission is on weekdays morning.
Kerala
- Cashless is widely available in multi-speciality hospitals in Kochi, Trivandrum, Calicut.
- Preferred: Aster Medcity, Amrita Institute.
Tamil Nadu (Chennai & Coimbatore)
- Chennai has large network: Apollo, MIOT, Global.
- Tip: Apollo Chennai’s TPA office works 24/7 for emergencies.
Punjab & Haryana
- Key: Fortis Mohali, PGIMER Chandigarh (partial cashless).
- Tip: Punjab network often covers private nursing homes — check list for smaller towns.
Rajasthan (Jaipur)
- Preferred: Fortis Jaipur, Eternal Heart Care.
- Tip: Many Jaipur network hospitals provide policy number-based pre-approval.
West Bengal (Kolkata)
- Preferred: AMRI, Apollo Gleneagles, Fortis Anandapur.
- Tip: Some hospitals in Kolkata accept soft-copy pre-authorization forms.
General Tip: Always print your insurer’s latest hospital network list before traveling to another state.
Additional Case Studies — Real-World Scenarios
Case Study 4: Pre-existing Condition Disclosure
Situation: Mr. Sharma had diabetes for 5 years but did not disclose it when buying policy.
Claim: Bypass surgery after 18 months of policy.
Outcome: Rejected — non-disclosure of pre-existing disease.
Lesson: Always disclose pre-existing conditions; hiding them can void claims.
Case Study 5: Ambulance Charges
Situation: Policy covered ambulance charges up to ₹3,000. Hospital billed ₹5,500.
Outcome: ₹3,000 reimbursed, rest borne by insured.
The Insurance Regulatory and Development Authority of India (IRDAI) is the apex body that regulates insurance in India. If your insurer does not resolve your complaint within 15 days, you can escalate to IRDAI or the Insurance Ombudsman. Note: This is a sample HTML form for demonstration. Official submission must be done via Bima Bharosa Portal or by emailing complaints@irdai.gov.in. You can approach the Insurance Ombudsman if your claim is rejected or if you face delays. Below is the complete contact list. The Insurance Regulatory and Development Authority of India (IRDAI) issues strict rules to protect policyholders. Understanding these rules can help you avoid delays and unfair rejections. If your grievance remains unresolved after approaching your insurer and IRDAI, you can escalate to the Insurance Ombudsman. Below is the complete zone-wise contact directory. Note: Before approaching the Ombudsman, you must wait for 30 days after filing your complaint with the insurer or IRDAI. Understanding these terms can make the difference between a successful claim and a costly rejection. Each definition includes a plain-English meaning, an example, and a practical tip.IRDAI Forms & Insurance Ombudsman Contact Directory
IRDAI Complaint Registration Form (Sample)
Step-by-Step Guide to Escalating Complaint to IRDAI
Insurance Ombudsman — Zonal Directory
Location
Jurisdiction
Address
Phone
Email
Ahmedabad
Gujarat, UT of Dadra & Nagar Haveli, Daman & Diu
Office of the Insurance Ombudsman, 2nd Floor, Ambica House, Near C.U. Shah College, Ashram Road, Ahmedabad – 380014
079-27546139 / 27546148
insombahd@cioins.co.in
Bengaluru
Karnataka
Office of the Insurance Ombudsman, Jeevan Soudha Building, PID No. 57-27-N-19, Ground Floor, 19/19, 24th Main Road, JP Nagar 1st Phase, Bengaluru – 560078
080-26652048 / 26652049
insombengaluru@cioins.co.in
Bhopal
Madhya Pradesh, Chhattisgarh
Janak Vihar Complex, 2nd Floor, 6, Malviya Nagar, Opp. Airtel Office, Bhopal – 462003
0755-2769201 / 2769202
insombhopal@cioins.co.in
Bhubaneswar
Odisha
62, Forest Park, Bhubaneswar – 751009
0674-2596461 / 2596455
insombbsr@cioins.co.in
Chandigarh
Punjab, Haryana, Himachal Pradesh, UT of Chandigarh
S.C.O. No. 101-103, 2nd Floor, Batra Building, Sector 17-D, Chandigarh – 160017
0172-2706196 / 2706468
insombchd@cioins.co.in
Chennai
Tamil Nadu, UT of Puducherry (except Mahe)
Fatima Akhtar Court, 4th Floor, 453, Anna Salai, Teynampet, Chennai – 600018
044-24333668 / 24335284
insombchennai@cioins.co.in
Delhi
Delhi, UT of Lakshadweep, Andaman & Nicobar Islands
2/2 A, Universal Insurance Bldg., Asaf Ali Road, New Delhi – 110002
011-23239633 / 23237532
insombdelhi@cioins.co.in
Guwahati
Assam, Meghalaya, Manipur, Mizoram, Arunachal Pradesh, Nagaland, Tripura
Jeevan Nivesh, 5th Floor, Nr. Panbazar Overbridge, S.S. Road, Guwahati – 781001
0361-2632204 / 2632205
insombguwahati@cioins.co.in
Hyderabad
Andhra Pradesh, Telangana, UT of Yanam
6-2-46, 1st Floor, Moin Court, Lane Opp. Saleem Function Palace, A.C. Guards, Lakdi-ka-pool, Hyderabad – 500004
040-23312122 / 23376599
insombhyd@cioins.co.in
Kolkata
West Bengal, Sikkim, UT of Andaman & Nicobar Islands
Hindustan Building Annexe, 4th Floor, 4, Chittaranjan Avenue, Kolkata – 700072
033-22124339 / 22124346
insombkol@cioins.co.in
Kochi
Kerala, UT of Mahe, Lakshadweep
2nd Floor, Pulinat Bldg., Opp. Cochin Shipyard, M.G. Road, Ernakulam – 682015
0484-2358759 / 2359338
insombkochi@cioins.co.in
Lucknow
Uttar Pradesh, Uttarakhand
6th Floor, Jeevan Bhawan, Phase-II, Nawal Kishore Road, Hazratganj, Lucknow – 226001
0522-2231330 / 2231331
insomblucknow@cioins.co.in
Mumbai
Maharashtra, Goa
3rd Floor, Jeevan Seva Annexe, S.V. Road, Santacruz (W), Mumbai – 400054
022-26106928 / 26106930
insombmumbai@cioins.co.in
Patna
Bihar, Jharkhand
1st Floor, Kalpana Arcade Building, Bazar Samiti Road, Malahi Pakri, Patna – 800004
0612-2680952 / 2680953
insombpatna@cioins.co.in
Pune
Maharashtra (excluding Mumbai Metro), Goa
Jeevan Darshan Building, 3rd Floor, C.T.S. No. 1983, N.C. Kelkar Road, Narayan Peth, Pune – 411030
020-32341320 / 32341321
insombpune@cioins.co.in
IRDAI Guidelines on Health Insurance Claims
Key IRDAI Rules
Common IRDAI Circulars for Policyholders
Insurance Ombudsman Offices — Contact List (India)
Centre
Jurisdiction
Address
Email
Phone
Ahmedabad
Gujarat, UTs of Dadra & Nagar Haveli, Daman & Diu
2nd Floor, Ambica House, Nr. C.U. Shah College, Ashram Road, Ahmedabad-380014
ombudsmanahmedabad@cioins.co.in
079-27546150
Bengaluru
Karnataka
Jeevan Soudha Bldg, PID No. 57-27-N-19, Ground Floor, 19/19, 24th Main Road, JP Nagar, Bengaluru-560078
ombudsmanbengaluru@cioins.co.in
080-26652048
Bhopal
Madhya Pradesh & Chhattisgarh
Janak Vihar Complex, 2nd Floor, 6 Malviya Nagar, Bhopal-462003
ombudsmanbhopal@cioins.co.in
0755-2769201
Bhubaneswar
Odisha
62, Forest Park, Bhubaneswar-751009
ombudsmanbhubaneswar@cioins.co.in
0674-2596461
Chandigarh
Punjab, Haryana, Himachal Pradesh, UT of Chandigarh
S.C.O. No. 101-103, 2nd Floor, Batra Building, Sector 17-D, Chandigarh-160017
ombudsmanchandigarh@cioins.co.in
0172-2706196
Chennai
Tamil Nadu, UT of Pondicherry
Fatima Akhtar Court, 4th Floor, 453 Anna Salai, Teynampet, Chennai-600018
ombudsmanchennai@cioins.co.in
044-24333668
Sample IRDAI Complaint & Claim Forms
Form 1: Health Insurance Claim Form (Generic)
1. Policy Number:
2. Name of Policyholder:
3. Name of Patient:
4. Hospital Name & Address:
5. Date of Admission:
6. Date of Discharge:
7. Nature of Illness/Disease:
8. Total Claim Amount:
9. Documents Attached:
- Discharge Summary
- Hospital Bills
- Prescriptions
- Diagnostic Reports
10. Bank Account Details:
- Account Number
- IFSC Code
- Bank Name
Signature: ____________________
Date: ________________________
Form 2: IRDAI Grievance Redressal Form
1. Name of Complainant:
2. Address:
3. Contact Number:
4. Email:
5. Policy Number:
6. Nature of Complaint:
7. Date of Complaint to Insurer:
8. Response Received from Insurer:
9. Relief Sought:
Signature: ____________________
Date: ________________________
Health Insurance Mega Glossary — 100+ Terms You Must Know
Example: Slipping on wet stairs and breaking a bone.
Tip: Most policies cover accidental injuries without a waiting period.
Example: Room rent waiver or maternity cover.
Tip: Always compare the add-on cost with the possible benefit before purchasing.
Example: 18–65 years in most plans; some allow entry till 70.
Tip: Buy early to lock in lifetime renewability.
Example: If limit is ₹5 lakh, claims beyond that won't be covered that year.
Tip: Choose a limit based on city hospital costs.
Example: Ayurvedic treatment for arthritis at a certified center.
Tip: Ensure your policy explicitly covers AYUSH if you prefer alternative medicine.
Example: If you have ₹5 lakh coverage and claim ₹2 lakh, your balance is ₹3 lakh.
Tip: Some policies restore the balance automatically for unrelated illnesses.
Example: A ₹3 lakh individual cover without maternity or critical illness add-ons.
Tip: Always check the base benefits before buying riders.
Example: Your spouse listed as nominee.
Tip: Update nominee details after major life events.
Example: Undergoing surgery in a network hospital without paying upfront.
Tip: Always confirm cashless approval before admission.
Example: Calling your insurer's helpline before planned hospitalization.
Tip: Intimate within 24 hours for emergencies and 48–72 hours for planned admissions.
Example: 20% co-pay means you pay ₹20,000 on a ₹1 lakh bill.
Tip: Choose low or zero co-pay if you're younger and in good health.
Example: Cancer, kidney failure, or stroke.
Tip: Check survival period clauses — typically 30 days after diagnosis.
Example: Cataract surgery or dialysis.
Tip: Ensure your policy lists all covered day care procedures.
Example: ₹50,000 deductible means insurer pays only after you spend ₹50,000.
Tip: Higher deductibles reduce premium but increase your out-of-pocket risk.
Example: Spouse, children, and dependent parents.
Tip: Some policies allow unmarried daughters up to age 25.
Example: Cosmetic surgery or self-inflicted injuries.
Tip: Read exclusions carefully to avoid surprises.
Example: ₹5 lakh floater for a family of four.
Tip: Works best when family members are of similar age and health.
Example: Returning the policy after finding hidden exclusions.
Tip: Use this period to read every clause carefully.
Example: 30 days grace for annual renewal.
Tip: Claims during grace period may be denied — renew before expiry.
Example: Employer-provided medical cover.
Tip: Check if you can continue coverage after leaving the group.
Example: Staying 4 days in a hospital for pneumonia.
Tip: Ensure the hospital is registered and recognized by your insurer.
Example: An insurer with 90% ICR pays ₹90 for every ₹100 collected.
Tip: ICR between 70–90% is generally healthy for long-term claim reliability.
Example: Apollo Hospital listed in the insurer’s network.
Tip: Always check the updated list before treatment.
Example: Filing a complaint if your claim is unfairly rejected.
Tip: Use this free service before going to court.
Example: Regulates all insurers in India.
Tip: Visit IRDAI website for official rules and consumer protection info.
Example: Smokers may pay 20% extra.
Tip: Maintain good health to avoid loadings.
Example: ₹50,000 cover for normal or C-section delivery.
Tip: Check waiting period (often 2–4 years).
Example: Covers hospitalization up to ₹5 lakh.
Tip: Compare with comprehensive health plans for wider cover.
Example: Fortis Hospitals under your plan’s list.
Tip: Go to network hospitals to avoid reimbursement hassles.
Example: 20% increase in sum insured.
Tip: Protect NCB by paying small expenses yourself.
Example: Doctor consultation for fever.
Tip: Some policies cover OPD costs.
Example: Moving from insurer A to B after 3 years.
Tip: Apply at least 45 days before renewal.
Example: Diabetes, hypertension.
Tip: Disclose honestly to avoid claim denial.
Example: Tests done 15 days before surgery.
Tip: Usually covered up to 30 days.
Example: ₹15,000 yearly.
Tip: Pay on time to avoid lapses.
Example: Filled with personal and health details.
Tip: Fill accurately to prevent disputes.
Example: ₹60,000 for appendix surgery in Delhi.
Tip: Excess charges may not be reimbursed.
Example: Paying ₹1.5 lakh for surgery and claiming later.
Tip: Keep all original bills and discharge summary.
Example: Restoring ₹5 lakh after a ₹5 lakh claim.
Tip: Often applies to unrelated illnesses.
Example: ₹3,000/day limit.
Tip: Higher category rooms may cause proportionate deductions.
Example: ₹50,000 sub-limit for cataract surgery.
Tip: Avoid low sub-limits to prevent out-of-pocket costs.
Example: ₹10 lakh annual coverage.
Tip: Choose adequate sum insured considering inflation and family size.
Example: MediAssist processing your hospital bills.
Tip: Keep TPA contact handy for emergencies.
Example: ₹10 lakh top-up after ₹5 lakh deductible.
Tip: Cheaper than increasing base policy sum insured.
Example: 4-year wait for pre-existing diseases.
Tip: Buy early to complete waiting periods sooner.
Example: Tier-1 cities pay higher premiums.
Tip: If possible, choose a lower zone for affordability.
Example: ₹2 lakh for fracture treatment.
Tip: Useful for high-risk professions.
Example: ₹2,500 ambulance expense reimbursement.
Tip: Check if air ambulance is included.
Example: ₹1,000/day hospital cash.
Tip: Can be used for incidental expenses.
Example: CSR of 96% means 96 out of 100 claims are paid.
Tip: Prefer insurers with CSR above 90%.
Example: Diabetes and hypertension together.
Tip: Disclose all conditions to avoid claim rejection.
Example: ₹10 lakh payout on cancer detection.
Tip: Use for income replacement during recovery.
Example: ₹1 lakh deductible before top-up applies.
Tip: Higher deductible reduces premium.
Example: Spouse, children, parents.
Tip: Confirm age limits for dependent children.
Example: Diabetes care program by insurer.
Tip: Join for better control and lower hospitalization risk.
Example: Adding in-laws increases premium.
Tip: Balance members between individual and family plans.
Example: 15-day period after policy issue.
Tip: Read terms carefully during this period.
Example: 30-day grace for renewal.
Tip: Avoid claims during grace period as they may not be covered.
Example: Employer-provided health cover.
Tip: Take individual cover too for continuity after job change.
Example: ₹2,000/day cash.
Tip: Good for incidental expenses not covered by main policy.
Example: ₹10,000/day ICU charges.
Tip: Check if ICU charges are capped.
Example: ₹5 lakh cover each for husband and wife.
Tip: Avoid sharing sum insured if high medical needs expected.
Example: Surgery with 3-day stay.
Tip: Distinct from OPD services.
Example: Renewal allowed even at age 85.
Tip: Mandatory as per IRDAI guidelines.
Example: No cover for cosmetic surgery.
Tip: Read policy exclusions carefully.
Example: 8 years under IRDAI rules.
Tip: Maintain continuous coverage to benefit.
Example: Max Hospital under insurer’s network.
Tip: Use for cashless benefits.
Example: Small local clinic.
Tip: Claims here are usually reimbursement-based.
Example: Medicines not covered by policy.
Tip: Keep emergency medical fund ready.
Example: PDF or printed file with all conditions.
Tip: Store safely for claim references.
Example: 1-year, 2-year or 3-year term.
Tip: Long-term plans often give discounts.
Example: No reset of PED waiting period.
Tip: Ensure porting request is on time.
Example: Getting cashless approval before surgery.
Tip: Speeds up hospital admission.
Example: 15% hike after a major claim.
Tip: Negotiate if unjustified.
Example: Paying ₹12,000 to continue coverage.
Tip: Never let policy lapse.
Example: ₹4,000/day max.
Tip: Choose policy without strict caps.
Example: Maternity cover rider.
Tip: Buy riders only if needed.
Example: Medical tests before policy issue.
Tip: Provide accurate health data.
Example: Shifting from general ward to private room.
Tip: May affect claim proportion.
Example: ₹20,000 uncovered due to sub-limit.
Tip: Understand possible shortfall before treatment.
Example: Preferred by many for comfort.
Tip: Check policy coverage for this room type.
Example: 2 years for hernia cover.
Tip: Read disease list carefully.
Example: ₹5 lakh coverage.
Tip: Same meaning as sum insured.
Example: ₹80,000 for gall bladder removal.
Tip: Check surgery list covered.
Example: Doctor call during COVID lockdown.
Tip: Some policies cover telemedicine costs.
Example: Late-stage cancer.
Tip: Certain policies offer lump sum payout.
Example: ₹50 lakh cover for overseas treatment.
Tip: Always take when traveling internationally.
Example: Reviewing health check results.
Tip: Being transparent improves approval chances.
Example: Experimental herbal therapy.
Tip: Usually not covered by insurance.
Example: Flu shots.
Tip: Rare in regular plans but common in wellness riders.
Example: 4 years for diabetes.
Tip: Buy early to reduce wait time.
Example: Gym membership discounts.
Tip: Engage to earn premium discounts.
Example: Zone 1: Metro cities.
Tip: Moving zones may change premium.
Example: Filled and signed claim form with bills.
Tip: Fill accurately and attach all documents.
Example: Used for tracking status.
Tip: Quote this number in all communications.
Example: Cataract surgery.
Tip: Covered in most modern plans.
Example: Treatment at home due to bed shortage.
Tip: Needs doctor certification.
Example: New hospital added for cashless facility.
Tip: Check updated list yearly.
Example: Cosmetic surgery.
Tip: Always read the exclusion list.
Example: ₹10 lakh floater for 4 members.
Tip: Works well if not all members claim often.
Example: 5000+ hospitals nationwide.
Tip: Choose insurer with wide network.
Example: You, spouse, children.
Tip: Ensure names are correct in documents.
Example: Calling within 24 hours of emergency admission.
Tip: Mandatory for smooth claims.
Example: Missing renewal date.
Tip: Set reminders for renewals.
Example: ₹20,000 limit for ambulance.
Tip: Note all limits before buying policy.
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