Your Cashless Claim Was Denied. What Now?

A cashless denial at the hospital is stressful, but it is not the end of your claim. In most cases you can recover the full amount through reimbursement if you act correctly.

Step 1 — Immediate

Do Not Leave the Hospital. Ask for Denial in Writing.

The TPA is legally required to provide a written denial with the specific reason for rejection. Do not accept a verbal denial. Request the written denial letter before making any payment decisions.

Key: The written denial reason determines your next steps. Common reasons: policy not active, pre-authorisation not sought, treatment not covered, hospital not in network.

Step 2 — Within 1 Hour

Call Your Insurer Directly — Not the TPA

TPAs are intermediaries and sometimes make errors. Call your insurer's toll-free helpline directly and escalate the denial. Provide your policy number, hospital name, and reason given for denial.

Important: Note the name and employee ID of every person you speak to, and the time of each call. This creates a documented escalation trail.

Step 3 — If Escalation Fails

Pay the Hospital and Switch to Reimbursement

If the insurer cannot resolve the denial in time and treatment is urgent, pay the hospital directly and collect all original documents. File for reimbursement within 15-30 days of discharge.

Documents to collect: Original discharge summary, itemised bill with receipt, all lab reports with prescriptions, doctor's certificate, and the TPA's written denial letter.

Step 4 — After Discharge

File a Formal Grievance Alongside Your Reimbursement Claim

Submit your reimbursement claim and simultaneously file a formal grievance with your insurer citing the wrongful denial of cashless facility. Escalate to IRDAI's Bima Bharosa portal if no response within 14 days.

Your right: If cashless is wrongfully denied, the insurer must pay reimbursement plus any additional hospital charges caused by the denial — over and above policy limits.

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