Health Insurance Claim Process Explained | Cashless, Reimbursement & Rejected Claims

2 min 24 sec · 26 August 2026 · nyvo

What to do when you or your family are in hospital. The video covers both routes a claim can take, cashless at a network hospital and reimbursement afterwards, how each differs for a planned admission and an emergency, and the escalation path if the claim is rejected: the reason in writing, then a grievance, then Bima Bharosa, then the Insurance Ombudsman.

What this video says

  • There are two kinds of hospitalisation, planned and emergency, and the video says 80% to 90% of hospitalisations in India are planned (nyvo's current data: nyvo does not publish this figure).
  • For a planned admission, such as a knee replacement or kidney stone treatment, inform the insurer 48 hours before; the video says the insurer then approves cashless treatment within 48 hours (correction: the insurer must decide any cashless request within 1 hour; the 48 hours is the advance notice for a planned admission, under the IRDAI Master Circular of 29 May 2024).
  • In an emergency, a family member should tell the hospital at admission that the patient is insured; the hospital requests cashless approval, which the video says the insurer must answer within 1 hour (this matches the IRDAI Master Circular of 29 May 2024), and the insurer pays the hospital at discharge.
  • If cashless is not approved, you can pay and claim reimbursement later by submitting the documents.
  • If a claim is rejected, get the reason in writing, then escalate: the insurer's grievance cell, then IRDAI's Bima Bharosa portal, then the Insurance Ombudsman, an independent body whose decision the video says the insurer has to accept (nyvo's current data: Bima Bharosa is not a required step before the Ombudsman, and the Ombudsman's order binds the insurer up to ₹30 lakh but does not bind the policyholder).
  • The video says an expert advisor such as nyvo helps get cashless claims approved and fights for you if they are not.

Figures to check against today's data

The video was recorded on 26 August 2026. Where nyvo's current data states a figure differently, it is below.

In the videonyvo's current data
0:1580 to 90% of all hospitalization in India are planned.Not in nyvo's published data.
0:30Within 48 hours, insurer will approve that your claim can go through cashless process.The insurer must decide a cashless request within 1 hour of receiving it, planned or emergency (IRDAI Master Circular on Health Insurance Business, 29 May 2024). The 48 hours is the advance notice to give before a planned admission.
0:36Now in this process, claim is already approved. You don't need to get into any kind of effort.Pre-authorisation approves an amount, which is the insurer's maximum rather than the final bill. Final authorisation at discharge is a separate step, due within 3 hours, and co-pay or non-payable items can still be charged to you.
1:33If you don't get any positive response, you can go to Bima Bharosa website ... And even if that is not sorted, you can go to insurance ombudsman.Both routes need a complaint to the insurer first and 30 days; Bima Bharosa is not a required step before the Ombudsman. Bima Bharosa pushes the insurer to respond but does not decide the case; the Ombudsman does.
1:57And this decision insurance company has to accept.The Ombudsman's order is binding on the insurer up to ₹30 lakh and must be implemented within 30 days. It is not binding on the policyholder, who can still go to a consumer court.

Chapters

Chapters as published with the video.

Transcript

From the video's English captions, with misheard names corrected. Tap a time to play from that point.

Read the full transcript

0:00The most important thing in health insurance is claim.

0:03And now let me tell you the detailed process of claims so that anytime you get hospitalized, you or your family know how to get the claim process. There are two types of hospitalization.

0:11One is planned hospitalization and another is emergency hospitalization. 80 to 90% of all hospitalization in India are planned.

0:20So in a planned hospitalization, what you should do is inform the insurer 48 hours before that you have that planned hospitalization. It may be something related to knee replacement, it may be something related to kidney stone, etc. Within 48 hours, insurer will approve that your claim can go through cashless process.

0:36Now in this process, claim is already approved. You don't need to get into any kind of effort.

0:42Second, in case of emergency hospitalization, it's important that family member during the admission inform that you have insurance. In this scenario, hospital can raise the request for cashless claim and within 1 hour, the insurance company has to tell if the cashless claim is approved or not. If the cashless claim is approved, during the discharge, the insurance company will pay the amount to the hospital and your discharge will be smooth.

1:05Period of hospitalization, you can request them to approve the cashless claim or later claim the reimbursement by submitting the documents.

1:12Now coming to a part when insurance company rejects the claim.

1:19First, they have to give you a reason. Get that reason in writing. Second, if you don't agree with the reason, there are three kind of escalations you can do.

1:27First, you can submit all the documents to the grievance cell of insurance company.

1:31If you don't get any positive response, you can go to Bima Bharosa website and you can raise the grievance there. There, the IRDAI regulator also is looped in the email and insurance company has to give you a response why they rejected the claim.

1:46And even if that is not sorted, you can go to insurance ombudsman. Insurance ombudsman is an independent party. They will hear insurance company and you in an unbiased manner and then they will give you the final decision. And this decision insurance company has to accept.

2:01I understand this is a long process, and nobody wants to get involved into this. That's why you need an expert advisor while buying the policy. nyvo guides you during your claim processes so that your cashless claim gets approved. Or if not, they will stand in view and fight for you.

2:19So, reach out to us in case of you need any expert guidance on insurance.

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Everything in this video, written out with the numbers and the sources.

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