The Health Insurance Claim Settlement Timeline

Filing a health insurance claim and waiting for the money to arrive can feel like a black box. The good news is that it does not have to be — IRDAI has established clear, enforceable turnaround time (TAT) standards for claim settlement, and every policyholder has the right to hold their insurer to these timelines. Understanding the full claim settlement journey from intimation to payment helps you track your claim, follow up effectively, and escalate when necessary.

The IRDAI-Mandated Turnaround Times

IRDAI''s 2016 Health Insurance Regulations, updated subsequently, specify maximum timelines for each stage of the claim process:

• Cashless pre-authorisation (planned admission): Decision within 1 hour of receiving all required information
• Cashless pre-authorisation (emergency): Decision within 1 hour from the time of request
• Cashless final discharge settlement: Insurer must settle the hospital directly within 2 hours of receiving the final bill at discharge
• Reimbursement claim — acknowledgement: Within 3 working days of receiving the claim
• Reimbursement claim — settlement or repudiation: Within 30 days of receiving all documents (with no investigation required)
• Claims requiring investigation: Must be settled or repudiated within 45 days of intimation
• Penal interest: If the insurer exceeds the 30-day limit without investigation, they must pay a 2% per month penal interest on the outstanding claim amount

The Full Claim Journey: Step by Step

1. Intimation: Notify insurer (Day 0)
2. Pre-authorisation (cashless): Hospital submits, insurer responds within 1 hour
3. Treatment: Hospitalisation period
4. Discharge settlement (cashless): Insurer pays hospital within 2 hours of final bill
5. Reimbursement claim submission: You submit within the policy''s stipulated window (15–30 days after discharge)
6. Insurer acknowledgement: Within 3 working days
7. Document review and query (if any): Insurer may request additional documents — respond promptly as this extends the timeline
8. Settlement or repudiation: Within 30 days of receiving all documents
9. NEFT payment: Usually credited within 3–5 working days of settlement approval

What Causes Delays

• Incomplete initial claim submission requiring follow-up queries
• Discrepancies between the diagnosis code and the nature of treatment
• Claims flagged for investigation due to unusually high bills or suspected fraud (not common for straightforward cases)
• Non-response from the policyholder to information requests

How to Track Your Claim

All major insurers provide a claim tracking facility on their website and mobile app using your policy number and claim reference number. Check this regularly from Day 3 onwards after submission. If the status shows "pending" beyond 15 days without any query raised, call the claims helpline for a status update.

What to Do When the Timeline Is Breached

• Send a written email to the insurer''s grievance officer citing the IRDAI-mandated TAT and the penal interest provision.
• Escalate to the IRDAI Bima Bharosa portal (bimabharosa.irdai.gov.in) if the insurer does not resolve within 30 days of your grievance.
• File a complaint with the Insurance Ombudsman for disputes above a certain financial threshold.

Conclusion

Claim settlement is not at the insurer''s complete discretion — there are regulated timelines and financial penalties for violations. Knowing these timelines empowers you to track your claim, follow up assertively, and escalate if needed. When choosing a health plan, look for insurers with consistently strong claim settlement track records, and let the advisors at TruePolicy help you identify which insurers deliver on this commitment in practice.