How to claim health insurance in India

Disclose everything at the proposal stage. Non-disclosure of a pre-existing condition is the single largest cause of rejected claims in India, and it does not have to be deliberate — an undeclared condition discovered in your hospital records years later is enough. Once a policy has run for the period specified in the Insurance Act's incontestability provision, an insurer's ability to repudiate on non-disclosure grounds is substantially restricted, but that only helps if the policy has been running that long.

Understand your room rent limit. This is where most quiet deductions come from. If your policy caps room rent at a percentage of sum insured and you take a more expensive room, many policies apply a proportionate deduction to the entire bill — surgeon's fees, investigations, everything — not just to the room charge. A room upgrade of a few thousand rupees can therefore reduce a large claim by a substantial percentage. Policies without room rent limits cost more and are usually worth it.

Know your waiting periods. Initial waiting for illness (typically 30 days), specific waiting for listed conditions and procedures, pre-existing disease waiting, and maternity waiting all run from policy inception. Porting a policy to another insurer carries accrued waiting periods with it, which is the main reason to port rather than start fresh.

Read the non-payable items list. Consumables, gloves, syringes, administrative charges, food for attendants and dozens of other items are excluded as standard, and typically account for a meaningful share of a hospital bill. Some insurers offer a consumables cover rider.

Check whether your policy has co-payment (you pay a fixed share of every claim) or sub-limits on specific procedures — both are common in cheaper policies and in senior citizen plans.

Check that the hospital is in your insurer's network — the list is on the insurer's website and app, and it changes, so check for the current admission rather than relying on memory.

For planned treatment, ask the hospital's insurance desk to send a pre-authorisation request to the insurer or TPA at least 48 hours before admission. The request goes with the treating doctor's assessment, the estimated cost and your policy details.

For an emergency, get admitted first. Inform the insurer within 24 hours of admission — most policies require this — and the hospital desk will file the pre-authorisation. IRDAI has pushed insurers towards rapid decisions on cashless authorisation and on final discharge approval, so escalate if the desk says it is waiting indefinitely.

Carry your health card or policy number and a photo ID. The hospital will take these at admission.

Approval is usually granted for an initial amount and enhanced as the stay progresses. Denial of cashless is not denial of the claim — you can pay and file for reimbursement, and should say so at the desk rather than abandoning treatment.

At discharge, you settle only the non-payable items, any co-payment, and anything above your sum insured or sub-limits. Ask for the itemised bill and the deduction breakdown before paying, and question any deduction you do not understand — hospital billing errors are common and the desk will correct obvious ones.

Keep copies of everything even in a cashless claim: the discharge summary, the itemised bill, all reports and the pre-authorisation correspondence.

Inform the insurer of the admission within the policy's stated window, even though you are paying yourself. Late intimation is a rejection ground that is entirely avoidable.

Collect at discharge: the original itemised hospital bill with payment receipts, the discharge summary, all investigation reports and films, the doctor's prescriptions, the pharmacy bills with corresponding prescriptions, and the implant sticker and invoice if any device was used.

The single commonest reimbursement problem is a pharmacy bill with no matching prescription. Every medicine claimed must be traceable to a prescription — ask the treating doctor to write up anything administered that is not already documented, before you leave the hospital.

Submit the claim form with originals within the policy's window, commonly 15 to 30 days from discharge. Keep photocopies and scans of everything you hand over, and get an acknowledgement.

Pre-hospitalisation and post-hospitalisation expenses are covered for defined periods either side of the admission — typically 30 and 60 days — and are claimed separately with their own bills and prescriptions. A great many policyholders never claim these at all.

Day-care procedures that do not require 24 hours of hospitalisation are covered where listed in the policy — cataract, dialysis, chemotherapy and many others.

The insurer must settle or reject within the timelines set by IRDAI's regulations, and interest is payable on delayed settlement. Track the claim number and follow up in writing.

Get the rejection in writing with the specific policy clause relied on. A rejection that cites no clause is one you should challenge immediately, because the insurer is required to give reasons.

Check the reason against your policy wording. The frequent grounds are non-disclosure, a waiting period not completed, an exclusion, treatment not requiring hospitalisation, and late intimation — and several of these are arguable on facts.

File a grievance with the insurer's own grievance redressal officer, whose details are in the policy document and on the website. The insurer must respond within the regulatory timeline.

If unresolved after 30 days or if the response is unsatisfactory, go to the Insurance Ombudsman. It is free, requires no lawyer, covers disputes up to the prescribed limit, and its award is binding on the insurer — though not on you, so you retain the right to go elsewhere if you reject it. This is the strongest and least-used remedy in Indian insurance.

Alongside or instead, register on IRDAI's Bima Bharosa portal or call 155255. This does not adjudicate but it creates a regulatory record and frequently produces movement.

The consumer commission is also open — a rejected insurance claim is a deficiency in service, and cases can be filed online through e-daakhil without a lawyer.

Time limits apply to both the Ombudsman and the consumer route, so do not spend a year in correspondence with the insurer before escalating.