Insurance

What actually decides whether a health insurance claim gets paid

After ninety-odd health claims a year for two years, the pattern is plain. Outcomes turn on disclosure, the five-year moratorium and room-rent limits, not on what people worry about when they buy the policy.

19 September 2026 · Raja Banka · RHB Wealth Pro, Salt Lake, Kolkata

We handle something over ninety health claims a year, and have done for two years. Very little about how they turn out has anything to do with what people worry about when they buy the policy.

The five-year line

IRDAI's 2024 health insurance master circular set a moratorium of five years. Once a policy has run that long without a break, the insurer can no longer dispute a claim on the ground that something was not disclosed at the time of buying. After five years only proven fraud reopens the question, and it is the insurer who has to prove it.

Which means the risky window is the first five years. And within that window the problem is almost never medical. It is paperwork.

Disclosure

The usual reason a claim gets held up early on is something the proposer left out. A blood pressure prescription. A surgery from a decade ago. A consultation that seemed too minor to mention. Sometimes people leave these out to keep the premium down. More often they simply forget, because the form is long and the illness was years ago.

An insurer that knew about a condition and priced for it will pay. An insurer meeting it for the first time on a discharge summary will start asking questions, and those questions arrive at the worst possible moment.

Declaring more costs a little more in premium. It is the cheapest insurance you will ever buy on the policy itself.

Room rent

This one catches families who did nothing wrong.

Where a policy caps the room category and you take a better room, most policies do not simply charge you the room difference. They apply a proportionate deduction across the entire bill in the same ratio. Surgeon's fees, theatre charges, consumables, all of it. Upgrade the room by three thousand a night and you can find a quarter of a seven-lakh bill disallowed.

It is in the wording, it is not negotiable at the hospital counter, and the time to find out which category you are entitled to is before anyone is admitted.

Timelines you can hold them to

The 2024 circular also put clocks on the process, which hospitals do not always volunteer:

• One hour for a cashless decision on a planned procedure.
• Three hours for a cashless decision in an emergency.
• Three hours for final authorisation once the discharge summary goes in. This is the rule that ended the afternoon spent waiting in a room you have already vacated.
• Thirty days to decide a reimbursement claim, counted from complete papers.
• Thirty days of free-look from receiving the policy document, if you want to return it.

What we do

Mostly we make sure the file is complete before it goes in, and we make the phone calls so that nobody has to make them from a hospital corridor. A claim put together properly at admission rarely becomes an argument three weeks later.

Questions this raises

Can an insurer reject a health claim for non-disclosure after five years?

No. Under IRDAI's 2024 health insurance master circular, once a policy has run for five continuous years the insurer cannot dispute a claim on grounds of non-disclosure of pre-existing conditions. Only proven fraud remains actionable, and the burden of proving it rests with the insurer.

Why was only part of my hospital bill paid when I upgraded the room?

Many policies that cap the room category apply a proportionate deduction across the whole bill — surgeon's fees, theatre charges and consumables — in the same ratio by which the room rent was exceeded. The shortfall is therefore usually far larger than the room-rent difference alone.

How quickly must an insurer approve a cashless claim in India?

Under the 2024 IRDAI master circular, a cashless decision is due within one hour for a planned procedure and within three hours in an emergency. Final authorisation must follow within three hours of the discharge summary being submitted. Reimbursement claims must be decided within thirty days of complete documentation.

Should I disclose a minor pre-existing condition when buying health cover?

Yes. A declared condition is priced by the underwriter at the outset; an undeclared one becomes a claims dispute later. Disclosure typically raises the premium slightly and materially improves the likelihood that the policy pays when it is needed.