Frequent tussles between hospitals and insurers have made policyholders anxious about getting cashless approvals at the time of hospitalization.
At times, insurers suspend cashless coverage for certain hospitals or blacklist them; at other times, hospitals disallow cashless coverage for specific insurers. Even large chains like Max Hospitals have seen such stand-offs, with cashless unavailable for a few insurers’ customers.
In such situations, policyholders may need to draw on their emergency funds for immediate expenses and later file for reimbursement. While the reimbursement process can seem complex, knowing the steps well can help avoid delays and ensure claims are settled smoothly.
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TAT for reimbursement claims
The turnaround time (TAT) for insurers to settle reimbursement claims is 15 days from the date of submission of the last complete document, as per the Irdai’s Master Circular on Protection of Policyholders’ Interests, 2024.
Experts say reimbursement claims are typically settled within 3-5 days, and in most cases, within a week. Delays mainly occur due to missing documents or insurers seeking clarifications, said Neeraj Khushalani, founder of InsureSmart.
“Since hospitals don’t submit documents directly, customers often miss sharing important reports or the initial diagnosis. As the discharge summary outlines the full illness chronology, the claim team relies on it and requests any missing documents. This is the biggest reason for reimbursement delays,” he explained.
What should you do to avoid delays?
Keep a record of every single document and receipt you get from the hospital, including doctor prescriptions, pharmacy bills, and investigation reports.
“Policyholders should maintain a date-wise record of bills, reports and payments so the total claim amount can be easily tracked. This also clarifies whether the insurer has settled the full amount or made deductions. Non-medical items should be listed separately, as these are often a cause of disputes. Customers should not expect insurers to cover such charges,” said Khushalani.
Policyholders must file reimbursement claims within 30 days of discharge. “Any delay may lead to rejection. Insurers may still accept it if you provide a clear explanation, but it’s always safer to file within the deadline,” said chartered accountant Mayank Gosar, founder and chief executive, Softcon Capital.
He also advised checking the insurer’s latest list of blacklisted hospitals. “If the hospital where you take treatment is blacklisted, your reimbursement claim will not be accepted,” he cautioned.
