What should an employee do if a cashless claim is denied at the hospital?

If a cashless claim is denied at the hospital, the employee should ask for the denial in writing, contact the TPA to request reconsideration with additional medical justification, pay the hospital deposit to continue treatment, and file a reimbursement claim after discharge. A denied cashless request does not close the claim itself; the same admission can still be reimbursed once documents are submitted post discharge.

What are the steps to follow when cashless is denied?

Follow these steps in order:

1. Get the denial in writing from the TPA. The written denial must state the specific policy clause invoked. Verbal denials at the hospital insurance desk are not sufficient for escalation.
2. Call the TPA helpline printed on the health card. Ask whether the denial can be reviewed with additional documents, such as a fresh doctor's note explaining medical necessity.
3. Pay the hospital deposit to continue treatment. This prevents delay to critical care while the claim is contested.
4. Collect all treatment documents. Original bills, discharge summary, diagnostic reports, doctor's prescriptions, and the written denial letter.
5. File a reimbursement claim after discharge. Submit the complete set within the timeline stated in the policy (usually 15 to 30 days).
6. Escalate through Bima Bharosa if the reimbursement claim is also denied. The IRDAI grievance portal at bimabharosa.irdai.gov.in accepts complaints against any licensed insurer.
7. Approach the Insurance Ombudsman as the final step. The Ombudsman can award compensation up to Rs 50 lakh and typically resolves cases within 90 days.

Why does a cashless request get denied at admission?

Common reasons include the diagnosis appearing to fall inside a waiting period, the estimated treatment not matching the policy's covered list, incomplete pre-authorisation documentation from the hospital, or the TPA needing additional medical evidence before committing to payment. In some cases, the denial is procedural (missing documents) rather than substantive (policy exclusion), which is easier to reverse.

Does a cashless denial mean the treatment is not covered?

No. A cashless denial is a decision at the point of admission, not a final decision on the claim. If the treatment is otherwise covered under the policy, the employee can pay upfront and reclaim through the reimbursement track. The eligible amount is calculated using the same policy terms in both cases.

Can the employee ask the hospital for help?

Yes. The hospital's insurance desk deals with cashless denials routinely and can often clarify with the TPA whether additional information will resolve the issue. Where the hospital and TPA disagree on medical necessity, the treating doctor's note is the most useful additional document to submit.

What are the timelines an insurer must meet?

Under the IRDAI Master Circular on Health Insurance Business dated 29 May 2024, insurers must decide on cashless pre-authorisation within 1 hour of a complete request from the hospital, and issue final authorisation at discharge within 3 hours. Reimbursement claims must be decided within 30 days of receiving complete documents. Delays beyond these timelines attract interest at 2% above the bank rate.

How Plum approaches this

Plum's claims team intervenes at the point of denial for any employee covered under a Plum-managed group policy, working directly with the TPA to establish whether the denial is procedural or substantive and pushing for reconsideration where the policy supports it. Plum's claims NPS of 79 reflects this hands-on involvement, and cashless pre-authorisation on Plum-managed policies clears in a median of 45 minutes, well inside the IRDAI 1-hour ceiling. Plum coordinates across partner insurers including ICICI Lombard, HDFC ERGO, Bajaj Allianz, Star Health, Niva Bupa, and Aditya Birla Health Insurance, and places group cover for employers from 7 employees upward, with a dedicated escalation contact for HR and employees at each partner.

Frequently asked questions

Can the employee refuse to pay the hospital deposit?

The hospital is not obliged to continue treatment on credit if cashless is denied. Paying the deposit and reclaiming through reimbursement is usually the practical path.

Does a denied cashless claim affect the sum insured?

No. The sum insured is used only when a claim is settled, so a denied cashless request does not reduce the available cover.

Can the employee approach IRDAI directly?

The employee should first raise the grievance with the insurer's grievance officer. If unresolved within 15 days, Bima Bharosa (IRDAI's grievance portal) accepts the complaint.

Is the 1-hour cashless timeline enforceable?

Yes. The Master Circular imposes interest at 2% above the bank rate for delays beyond the timeline, and IRDAI monitors compliance through insurer disclosures.

Can the treating doctor influence the cashless decision?

The treating doctor's note explaining medical necessity is a key document at pre-authorisation. A well-drafted note can prevent avoidable denials on ambiguous diagnoses.

What if the reimbursement claim is also denied?

The employee has 90 days to approach the Insurance Ombudsman after escalation through Bima Bharosa. The Ombudsman's decisions are binding on the insurer.