Cashless claim denied at the hospital?

The insurer has to decide fast

• A cashless pre-authorisation request must be decided immediately, and within 1 hour of the insurer receiving it.
• The final discharge authorisation must come within 3 hours of the hospital’s request. If the insurer is late, any extra amount the hospital charges for the delay is borne by the insurer, not you.
• Insurers must publish their turnaround times for pre-authorisation, final bills and reimbursement on their website and in the customer information sheet.

A cashless refusal is not always a claim rejection

Insurers often refuse or cut cashless because the hospital’s papers are incomplete, the hospital isn’t in the network, or they want to check something first. In most policies you can still pay the hospital, then file a reimbursement claim with the full bills and discharge summary. Read the claims clause of your policy to confirm how it treats a cashless refusal.

Ask the hospital’s insurance desk for the insurer’s written refusal or query. You will need its exact reason later.

If you file for reimbursement

• Reimbursement claims must be settled within 15 days of submission.
• If the insurer is late, it must pay interest at bank rate plus 2% a year, without you asking.
• No claim can be rejected or closed only because documents are missing or the claim was intimated late. The insurer or TPA has to collect documents from the hospital.
• If the reimbursement claim is rejected or cut too, the letter must cite the specific policy clause it relies on.

What to do

1. During the stay: ask the hospital desk for the insurer’s written reason, and whether the hospital can send more papers for a fresh request.
2. After discharge: keep every bill, the discharge summary, reports and the refusal, and file the reimbursement claim with the insurer or TPA.
3. If the reimbursement claim is also refused or cut, write to the insurer’s Grievance Redressal Officer, then go to the Insurance Ombudsman if needed.