Why a cashless approval takes longer than an hour, and who is holding the file
What IRDAI says about the one-hour limit for cashless approval, whether a query stops the clock, and the points where a file waits, from hospital to doctor.
Published 1 November 2026.
A patient is admitted, the hospital sends a cashless request, and an hour later nobody has answered. Is the insurer late? Often the honest answer is: it depends on where the file is, and who is holding it. This note separates what the regulator says from what happens at a claims desk.
What the regulator says about the one hour
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.
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.
Where the file waits
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 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.
- The hospital’s request is incomplete. A request that arrives without a clear diagnosis, the treating doctor’s note, the investigation reports or an estimate cannot be decided properly. The insurer asks for them and the file waits for the hospital.
- Inwarding and registration. Requests arrive by e-mail, portal or fax and are registered by hand or by keying. A wrong member or policy number, a duplicate request or a request sent to the wrong mailbox adds time before anyone looks at the substance.
- Policy checks by the executive. Waiting periods, pre-existing conditions, sub-limits, endorsements and earlier claims all have to be checked, and a policy with unusual terms or a recent change takes longer to read correctly.
- Queries going back and forth. Each query goes to the hospital and the answer comes back to the same queue. Several small queries one after another cost much more time than one complete query.
- The queue for the processing doctor. At busy hours there are more files than doctors, and complex or high-value cases, such as surgery, intensive care or a long stay, are read more carefully or passed to a senior doctor.
- Systems, nights and holidays. Portal or e-mail downtime, a thin night or holiday desk and weekends when the usual approvers are away all slow a clock that does not stop for them.
Basis: Practice.
Try it on a sample case
The claim lifecycle page draws the clock for a cashless request on a synthetic case, using the same checks as the bill-audit worksheet, and lists where each wait happens. Its times are illustrative, not any real claim. Worksheet 1 lets you enter your own times and see when the clock turns late.
Related: Claim lifecycle. All notes.
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.