The short answer: a cashless claim is settled directly between a network hospital and the insurer or TPA after pre-authorization, so the policyholder does not pay the covered amount upfront. A reimbursement claim is one where the policyholder pays the hospital, then submits the documents to the insurer to be paid back, within the time limit set in the policy wording.
How a cashless claim works
Cashless claims are available at hospitals in the insurer's network. The hospital sends a pre-authorization request to the insurer or TPA, with the treatment details. For a planned admission, this happens before the patient is admitted. For an emergency, it happens after admission, within the window the policy sets. Once approved, the insurer or TPA settles the covered amount directly with the hospital. The policyholder pays only what the policy does not cover, such as amounts above a room rent limit or excluded items.
How a reimbursement claim works
At a hospital outside the network, or when cashless is not possible, the policyholder pays the bill and claims it back. They submit the claim form along with documents such as the discharge summary, itemized bills, payment receipts, and investigation reports, within the time limit in their policy wording.
The questions that come up every week
- "Is this hospital in my network?" The insurer's or TPA's network list answers it.
- "What is my room rent limit?" The policy wording sets it, often as a share of the sum insured or a fixed amount per day.
- "What documents do I need?" A clear checklist, specific to cashless or reimbursement, saves a round trip.
- "Where is my claim?" Status, and what is still pending, if anything.
- "How do I complain?" The grievance route below.
Each of these has a precise answer in the policy wording or the claim record. The problem is not finding the answer. It is giving the same correct answer every time, at any hour.
Where to escalate a grievance
In India, a policyholder who is unhappy with a claim decision first raises it with the insurer's grievance redressal officer. If it is not resolved, they can escalate through IRDAI's Bima Bharosa grievance portal, and then to the Insurance Ombudsman under the Insurance Ombudsman Rules, 2017. Showing this path, with the timelines your process commits to, sets expectations before frustration sets in.
Answering at scale
Support teams answer these questions all day. An assistant that answers from the policy wording, cites the clause, explains the documents needed, and hands anything judgment-based to a person takes the repetitive load off the team without changing who makes decisions.
ClaimKavach answers claim questions like these from the policy wording, with the clause cited, at any hour.