Two ways to claim: cashless and reimbursement
Every group health insurance claim in India follows one of two pathways. Understanding both before you ever need to use them prevents the panic and errors that often occur when employees try to navigate the process under the stress of an actual health event.
Cashless: The insurer pays the hospital directly. You pay little or nothing at discharge, only amounts specifically excluded by the policy.
Reimbursement: You pay the hospital in full, then submit bills and documents to the insurer for repayment. This is the fallback when a network hospital is not available or when cashless authorisation is declined.
Cashless claim process — planned hospitalisation
Follow these steps for any scheduled procedure or planned admission:
- Step 1 — Verify the hospital is in-network: Use your insurer's app or call the helpline. Never assume — a hospital can leave the network between your last check and the current admission.
- Step 2 — Intimate the insurer or TPA: Most insurers require notification 48–72 hours before planned admission. Call the helpline or use the app.
- Step 3 — Visit the hospital's insurance desk: Carry your e-health card (digital or printed), a valid photo ID, and the treating doctor's advice or prescription.
- Step 4 — Complete the pre-authorisation form: The hospital's TPA desk will help you fill this. It asks for diagnosis, proposed treatment, and expected admission dates.
- Step 5 — Await approval: The insurer typically responds within 1–4 hours for planned cases. An approved amount is communicated to both you and the hospital.
- Step 6 — Get treated and discharge: At discharge, review the final bill. Pay any balance that is not covered by the policy (consumables, non-medical expenses, amounts over your sum insured).
Cashless claim process — emergency admission
In an emergency, treatment comes first. But do the following as soon as practically possible (within 24 hours of admission):
- Inform the hospital's insurance desk that you are covered under a group policy and provide your e-health card or policy number
- Call the insurer's helpline to notify them of the emergency admission
- Request a retrospective pre-authorisation — most insurers accept these for genuine emergencies
Reimbursement claim process
If cashless is not available, follow these steps after discharge:
- Step 1 — Pay the hospital and collect all original bills: Do not accept printed invoices from hospital systems — insist on original bills with the hospital's rubber stamp and authorised signature.
- Step 2 — Collect all documents: See the checklist below.
- Step 3 — Submit within the policy timeframe: Most policies require submission within 15–30 days of discharge. Missing this deadline is the most common reason for rejection.
- Step 4 — Track your claim: Log the claim reference number and follow up if you don't receive an acknowledgement within 3 working days.
- Step 5 — Receive payment: Approved claims are settled within 7–15 working days from the date of complete document submission.
Document checklist
For reimbursement claims, gather:
- Duly filled claim form (available from insurer or TPA website)
- Original discharge summary from the hospital
- All original bills and receipts (hospitalisation, pharmacy, diagnostics)
- Investigation reports (lab reports, imaging, ECG, etc.)
- Treating doctor's prescription and consultation notes
- Copy of your e-health card or group policy number
- Cancelled cheque or bank details for direct transfer
- Photo ID (Aadhaar, PAN, or passport)
Common reasons claims are rejected — and how to avoid them
- Treatment not covered: Check the policy exclusions before admission. Contact your HR or the insurer's helpline if unsure.
- Missing documents: Never discard any bill or report until the claim is fully settled.
- Late submission: Set a reminder to submit within 15 days of discharge — don't wait for the deadline.
- Pre-existing condition not declared during endorsement: Under group policies, PED is generally covered, but the insurer will verify the timing of the condition's onset if a large claim is filed.
- Non-network hospital for cashless: If the network list changes, contact HR immediately — they should update employees.
Claim rejections are frustrating but often avoidable with preparation. Keep a digital copy of all documents in a dedicated folder on your phone, and make sure every family member covered under the policy knows where to find the e-health card and the helpline number.