Health insurance reimbursement claim: documents checklist, claim form and deadlines

What documents are needed for a reimbursement claim?

You need the claim form plus proof of what was treated, what was billed and what you paid. Insurers’ lists differ a little, but most ask for the documents below. Bills and receipts should be in the patient’s name.

If you have more than one health policy, IRDAI’s 2024 Master Circular on health insurance lets you choose which policy to claim under first, and that insurer coordinates the balance with the others.

Part A and Part B of the claim form: who fills what

Part A is filled in by you, the insured, and Part B by the hospital. IRDAI prescribed this standard claim form for insurers, TPAs and hospitals in a circular of 28 March 2016 under the TPA Regulations (Part C was the cashless request form), and insurer and TPA claim forms still commonly follow it.

Get Part B completed before you leave the hospital; chasing it later is the most common cause of delay. Fill in the insurance history honestly. It asks about other policies and the date your continuous cover began, which matter for coordinating claims and for waiting-period credit.

When do you need to inform the insurer and send documents?

Deadlines are set by your policy wording, not by regulation, but many wordings use similar ones:

Check the “claims procedure” section of your own wording, as the numbers vary.

What if you miss a deadline?

A missed deadline shouldn’t on its own sink your claim. IRDAI’s September 2024 policyholder-protection Master Circular says no claim shall be rejected or closed for want of documents or for delayed intimation, and many wordings already allow delays to be condoned on merit. Send the claim as soon as you can with a short letter explaining the delay, such as a continuing illness, travel or a death in the family, with proof where you have it.

The same rules require insurers to ask for all the documents they need at one go, not piecemeal. If the insurer keeps sending new requests, point this out in writing.

How do you claim pre- and post-hospitalisation expenses?

Claim them with the same illness as the hospital stay, within the number of days your policy covers before admission and after discharge. The number of days varies by policy and is shown in the schedule or Customer Information Sheet. Pre-hospitalisation bills usually go with the main claim. Post-hospitalisation bills go as a separate claim once that treatment is over. The standard Part A declaration says you won’t make any supplementary claim except the pre- and post-hospitalisation claim, so include every hospital bill the first time.

How long does the insurer have to settle?

Fifteen days from submission of the claim. IRDAI’s policyholder-protection Master Circular of 5 September 2024 says claims other than cashless must be settled within 15 days. If the insurer is late, it must pay interest at the bank rate plus 2% from the date it received intimation of the claim, on its own without being asked. The bank rate is the RBI Bank Rate on the first day of the financial year in which the claim fell due.

Older wordings may still print a rule of 30 days from the “last necessary document”, or 45 days if the insurer investigates. That came from regulations repealed in April 2024; the current rule is 15 days.

Example. You are discharged on 10 November 2026 after a hospital bill of ₹1,20,000. In the weeks before admission you spent ₹6,500 on consultations, tests and a ₹2,400 pharmacy bill. You submit the claim on 25 November, 15 days after discharge and inside a 30-day deadline. Follow-up visits and medicines after discharge cost ₹9,000, which you claim separately once that treatment ends.

The insurer should settle the main claim of ₹1,26,500 by 10 December 2026, 15 days after submission, subject to policy deductions. If the ₹2,400 pharmacy bill goes in without its prescription, that line is likely to be queried, so attach the prescription the first time.

What to check in your policy

1. Claims procedure section: search “notification of claim”, “intimation”, “documents to be submitted” and “within 30 days”.
2. Condonation: search “condone” or “delay” to see how late submissions are treated.
3. Pre- and post-hospitalisation: the number of days covered, in the schedule or Customer Information Sheet.
4. Claim settlement clause: search “claim settlement” or “penal interest”. If it still says 30 days, the 15-day rule in IRDAI’s September 2024 policyholder-protection Master Circular now applies.
5. KYC: search “KYC” for any claim amount above which full KYC is needed.
6. Multiple policies: search “contribution” or “multiple policies”.

Where people get caught out

• Leaving the hospital without Part B. Getting a stamp and signature weeks later is slow.
• Bills not in the patient’s name. A pharmacy bill in a relative’s name can be questioned.
• Missing prescriptions. Every test and medicine bill should have a matching doctor’s note.
• No implant sticker. Ask for the sticker or invoice before discharge; hospitals don’t always attach it.
• Sending only the summary bill. The itemised breakup is what the insurer assesses, and what you need to check any deductions.
• Not keeping copies. Photocopy or scan everything you send, with the date of submission.