The life of a health-insurance claim in India: turn-around times, and why claims run late
Follow an Indian health-insurance claim from admission to payment: the IRDAI turn-around time (TAT) limits, why claims run late, and what a policyholder can do.
Questions about turn-around time
What is turn around time (TAT) in claims, and who sets it?
TAT is the time an insurer or TPA is allowed to take over one step of a claim: deciding a cashless request, giving final authorisation at discharge, or settling a reimbursement claim. IRDAI sets the limits for the main steps, which are one hour, three hours and fifteen days (see the table above). For the other steps each insurer sets and publishes its own.
A TAT is always measured on a clock with a start event and a stop event. That is why the start and the stop in each picture on this page matter more than the length.
Basis: Official text, Practice. Master Circular on Health Insurance Business, 29 May 2024; Master Circular on Protection of Policyholders’ Interests, 5 September 2024.
What does IRDAI say about the one hour for cashless approval?
The insurer must decide the request for cashless authorisation immediately, and in any case within one hour of receiving the request. The circular required insurers to have the systems and procedures for this in place by 31 July 2024, and says they may set up help desks at the hospital and must also give pre-authorisation digitally.
Basis: Official text. Master Circular on Health Insurance Business, 29 May 2024; Master Circular on Protection of Policyholders’ Interests, 5 September 2024.
What does IRDAI say about the three hours for final approval at discharge?
The insurer must give final authorisation within three hours of receiving the discharge authorisation request from the hospital, and in no case may the policyholder be made to wait to be discharged. Worksheet 1 includes a timer for this: exactly three hours counts as within the limit.
Basis: Official text. Master Circular on Health Insurance Business, 29 May 2024; Master Circular on Protection of Policyholders’ Interests, 5 September 2024.
What happens if the insurer takes longer than three hours?
The extra amount the hospital charges because of the delay is borne by the insurer from the shareholders’ fund, not by the policyholder. Worksheet 1’s timer marks a final authorisation as late and flags that the extra charges fall on the insurer. It does not calculate the charge, and the circular text read does not say how the extra amount is measured.
Basis: Official text. Master Circular on Health Insurance Business, 29 May 2024.
Does a query stop the clock?
The circular text read does not say so. It states the hour and the three hours as limits from receipt of the request and is silent on pausing them for a query. Whether a pause is allowed is a question for the regulations and the contract, so treat any statement that a query always or never stops the clock with care.
In general practice across insurers and TPAs, the clock is treated as paused while the file waits for the hospital’s reply and restarts when the reply arrives. That is practice, confirmed by the site owner on 1 November 2026, not a rule found in the circulars.
Basis: Official text, Practice. Master Circular on Health Insurance Business, 29 May 2024; Master Circular on Protection of Policyholders’ Interests, 5 September 2024.
Why do cashless approvals so often take longer than an hour?
The common causes in claims practice are an incomplete request, a queue at registration, the policy checks, several rounds of queries, and the queue for the processing doctor, with complex or high-value cases taking longer. They are listed with their stage in the table of wait points below.
These are causes drawn from claims work, confirmed by the site owner on 1 November 2026, and are not statistics. Each one is a point where the file waits for somebody, and the person who is holding it is not always the insurer.
Basis: Practice.
Why can a patient wait hours for discharge even when the insurer is within three hours?
The three hours run from the insurer’s receipt of the hospital’s discharge authorisation request. Anything that happens before the request is sent, or inside the hospital after the authorisation arrives, is outside that clock.
In practice the wait is mainly inside the hospital: the final bill may be sent late, the pharmacy and billing may still be clearing, or the paperwork may not be ready. The site owner confirmed this on 1 November 2026. Sending the discharge request early and clearing those steps in parallel is what shortens the wait.
Basis: Official text, Practice. Master Circular on Health Insurance Business, 29 May 2024.
How long does a reimbursement claim take, and what if it is late?
Claims other than cashless are to be settled within fifteen days from submission of the claim. If a claim is not settled within the specified timelines, the claimant is entitled to interest at bank rate plus 2 percent from the date of receipt of intimation to the date of payment, and the insurer must pay it on its own.
The two statements use different starting points, submission for the fifteen days and intimation for the interest. This page reports them as written and does not say how an insurer or a court would reconcile them.
Basis: Official text. Master Circular on Protection of Policyholders’ Interests, 5 September 2024.
Can a claim be rejected for missing documents or late intimation?
The circular says no claim is to be rejected or closed for want of documents or for delayed intimation of the claim, and that insurers and TPAs collect the required documents from the hospitals rather than asking the policyholder to submit them.
A claim can still be repudiated on other grounds, such as an exclusion or a waiting period, but only with the approval described in the next answer.
Basis: Official text, Practice. Master Circular on Protection of Policyholders’ Interests, 5 September 2024; Master Circular on Health Insurance Business, 29 May 2024.
Who can reject a claim?
No claim can be repudiated without the approval of the Product Management Committee or its three-member sub-group, the Claims Review Committee, which takes the final decision on every repudiation. If a claim is repudiated or only partly allowed, the claimant must be given the details with reference to the specific terms of the policy.
Basis: Official text. Master Circular on Health Insurance Business, 29 May 2024.
What is the difference between a query, a partial approval, a denial of cashless and a repudiation?
A query asks for more information or documents before a decision. A partial approval allows the claim but disallows some lines or amounts, with reasons. A denial of cashless means the insurer will not pay the hospital directly at this stage, and the patient may still be able to pay and claim by reimbursement. These three are descriptions from claims practice.
A repudiation is a rejection of the claim. It needs the committee approval and the reasons described above.
Basis: Practice, Official text. Master Circular on Health Insurance Business, 29 May 2024.
What can a policyholder do when a claim is late or wrongly rejected?
Insurers must have a grievance redressal process, and the reply to a grievance must include the contact details of the Insurance Ombudsman where the complaint can be escalated. An Ombudsman’s award must be complied with within 30 days, with a penalty of Rs 5,000 a day if it is not. A claim not settled in time also earns interest, as above.
This page describes what the circulars say. It is not legal advice.
Basis: Official text. Master Circular on Health Insurance Business, 29 May 2024; Master Circular on Protection of Policyholders’ Interests, 5 September 2024.
Every case on this site is synthetic. These are working drafts and illustrations, not a claim decision or legal advice. The interactive worksheets need JavaScript; nothing is sent anywhere.