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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, issue final cashless authorisation at discharge within 3 hours, and settle reimbursement claims within 30 days of receiving complete documents. Delays beyond these timelines attract interest at 2% above the bank rate.
How long does a cashless claim take at admission?
Cashless pre-authorisation must be issued by the insurer or TPA within 1 hour of the hospital submitting a complete request. This applies to both planned and emergency admissions. If the request is incomplete because of missing documents, unclear diagnosis notes, or an ambiguous cost estimate, the 1-hour clock starts only when the missing information is received. The Master Circular reference is IRDAI/HLT/CIR/MISC/77/05/2024, dated 29 May 2024.
How long does cashless approval at discharge take?
Final cashless authorisation at discharge must be issued within 3 hours of the hospital submitting complete discharge documentation. If the insurer takes longer, the hospital's additional charges for the delay are borne by the insurer from its shareholder's fund, not by the employee. This provision came into force from 31 July 2024.
How long does a reimbursement claim take?
The insurer must decide on a reimbursement claim within 30 days of receiving complete documents from the policyholder. Complete documents typically include the filled claim form, original hospital bills, discharge summary, diagnostic reports, and doctor's prescriptions. If the insurer requests additional documents mid-review, the 30-day clock is paused until those documents are received.
What happens if the insurer misses these timelines?
The IRDAI Master Circular imposes interest at 2% above the bank rate on the claim amount for every day of delay beyond the mandated timeline. The employee does not need to file a separate application for this interest; the insurer is required to add it automatically to the settled amount. Where the insurer does not comply, the employee can escalate through Bima Bharosa (the IRDAI grievance portal) or the Insurance Ombudsman, which can award compensation up to Rs 50 lakh.
How long do pre- and post-hospitalisation expense claims take?
Pre-hospitalisation and post-hospitalisation expenses, covering the 30 or 60 days before and after admission as per policy terms, are filed as reimbursement claims and follow the same 30-day settlement timeline. Employees should submit these expenses after the main hospitalisation claim is settled, since the insurer needs the primary claim on file to process related expenses.
What causes claim settlement to take longer than expected?
Common reasons for delay include incomplete documentation at submission, discrepancies between hospital bills and the discharge summary, mismatched diagnosis codes, and pending clarifications from the treating hospital. Employees can shorten settlement time by submitting the complete document set on the first attempt and following up with the TPA within 7 days if no acknowledgement is received.
How Plum approaches this
Plum tracks every claim on its group health book against the IRDAI timelines, escalating to the TPA and insurer the moment a claim breaches the 1-hour, 3-hour, or 30-day mark. Cashless pre-authorisation on Plum-managed policies clears in a median of 45 minutes, well inside the 1-hour regulatory ceiling, and Plum's claims NPS of 79 reflects the settlement experience across cashless and reimbursement tracks. Plum works with 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 each partner's typical claim turnaround shared with the employer at the proposal stage.
Frequently asked questions
Does the 1-hour cashless rule apply to all insurers?
Yes. The rule is set under the IRDAI Master Circular on Health Insurance Business, 2024, and applies to every IRDAI-licensed health insurer in India.
What is the deadline to file a reimbursement claim?
Most policies require submission of reimbursement claim documents within 15 to 30 days of discharge, though specific timelines are stated in the policy document. Filing beyond the stated window can lead to rejection unless a valid reason for delay is accepted by the insurer.
Is intimation the same as filing a claim?
No. Intimation is the initial notice to the insurer that a hospitalisation has occurred, usually required within 24 to 48 hours of admission. The claim is filed later, either through the cashless workflow at the hospital or through the reimbursement process after discharge.
Can settlement take longer for a large claim amount?
No. The IRDAI-mandated timelines apply regardless of claim size. Higher-value claims may involve more back-and-forth on documentation, but the 30-day statutory clock still applies once documents are complete.
Does a delayed intimation void the claim?
Not automatically. If the delay in intimation was due to a genuine emergency and the claim is otherwise payable, IRDAI rules state the insurer should not reject it purely on procedural grounds.
How can an employee check claim status?
Claim status is available through the TPA's online portal, the insurer's mobile app, the toll-free helpline printed on the health card, or, for Plum-managed policies, through the Plum employee dashboard.
