Insurance Claim Process Guide: Life and Health Claims

The hospital insurance desk asks for the e-card while the patient is still being wheeled in — or, in the worst version of the story, a family sits at home with a death certificate and no idea which papers the insurer needs. Insurance claims in India run on published clocks, and the paperwork is a short list. Knowing both before you need them is the entire difference between a two-week payout and a six-month fight.

This guide walks the claim process end to end: the timelines the regulator enforces for life and health claims, the documents each claim needs, the interest that accrues automatically when an insurer is late, the reasons claims actually get rejected, and the escalation ladder that ends at the Insurance Ombudsman.

The clocks the regulator runs

None of the timelines below is an insurer courtesy. They are enforceable, and late payment carries automatic interest.

Source: IRDAI Master Circular on Protection of Policyholders' Interests, 2024, ref. IRDAI/PP&GR/CIR/MISC/117/9/2024, dated 5 September 2024. Insurers' board-approved policyholder protection policies implement the same table — LIC's published policy, for example, lists death claims at 15 and 45 days, surrender at 7 days, and non-cashless health claim settlement at 15 days (Source: LIC, Policy for Protection of Interests of Policyholders, 2024, licindia.in).

A death claim, step by step

Intimate the insurer first — branch, website, app or call centre all count. The circular is explicit that an intimation received by a distributor, TPA or hospital must be forwarded to the insurer immediately, so the date you first told anyone official is the date the clock starts (Source: IRDAI Master Circular on Protection of Policyholders' Interests, 2024).

Then the documents, and it is a short list: the claim form, the death certificate, and as applicable the FIR and post-mortem report for accidental deaths or the hospital discharge summary for deaths following treatment. The insurer must state its full requirement list inside the policy document and display it on its website — you are never dependent on a call-centre script to know what is needed (Source: the same circular, claim documents section).

Two mechanics decide how fast the money actually lands. First, routing: if the policy was assigned against a home loan, the nominee gives consent for the lender to be paid the outstanding balance directly, and any surplus goes to the nominee's own bank account — not the estate, not a joint account (Source: the same circular). Second, the settlement clock: 15 days without investigation, 45 where investigation is warranted — early claims, typically deaths within the first few years of the policy, are where the longer route applies, and the insurer must communicate its reasons.

The insurer owes you process, not just money: written acknowledgement of the intimation, one consolidated list of requirements, and no re-opening that list item by item to stretch the file. Where the death is an early claim, expect the 45-day route with investigation, and expect requests for medical records — that is normal underwriting hygiene at claim stage, and knowing it is normal keeps a family from reading bad faith into every letter.

One routing trap deserves its own paragraph: the nominee is the receiver, not always the final owner. Where a valid nomination exists, the insurer pays the nominee and the legal-heir questions, if any, stay outside the claim. Where no nomination exists, succession paperwork and every heir's signatures enter the process, and the 15-day clock becomes fiction. Fix nominations now — it is the cheapest claim acceleration that exists.

A health claim: cashless or reimbursement

Cashless is the default when the hospital is in network. The hospital files pre-authorisation with your e-card, and the insurer must decide within one hour of receiving the request. At discharge, final authorisation is due within three hours of the discharge request — and if the insurer is slower, any extra amount the hospital charges for the waiting is borne by the insurer from its shareholders' funds, not by you. If the policyholder dies during treatment, the insurer must immediately process the claim and get the mortal remains released from the hospital (Source: IRDAI Master Circular on Protection of Policyholders' Interests, 2024, health claim section).

Reimbursement is the fallback — planned treatment at a non-network hospital, or an emergency where cashless failed. The insurer must settle within 15 days of receiving the complete documents: bills in original, discharge summary, prescriptions, diagnostics and KYC. Reimbursement claims die on missing paperwork, not on insurer reluctance. Keep every page, photograph them, and hand over copies while holding the originals.

What makes those health approvals work is the fine print you accepted at purchase — the room-rent caps and waiting periods our complete health insurance guide dissects. A clean claim on the wrong room category still pays less than the bill.

The interest clock: bank rate plus 2%

Late payment is not something you have to argue for. If a claim is not settled within its timeline, interest at the bank rate plus 2% accrues from the date of intimation to the date of payment, and the insurer must pay it suo-moto, along with the claim (Source: IRDAI Master Circular on Protection of Policyholders' Interests, 2024).

The arithmetic, illustratively: on a Rs 50 lakh death claim paid 10 days late, at a bank-rate-plus-2% that works out to, say, 7.75% a year, the interest is roughly Rs 10,616 (50,00,000 × 7.75% × 10/365). The number is small on short delays; the value is in knowing the clock exists, because insurers behave differently with claimants who do.

Maturity and surrender claims: the quiet ones

Death claims get the attention; the servicing claims are where most money actually moves. A maturity claim is due on the due date — not a fortnight later while systems process — and surrender or partial withdrawal must be paid within 7 days of the request, with the same bank-rate-plus-2% interest attaching when these clocks are missed (Source: IRDAI Master Circular on Protection of Policyholders' Interests, 2024). Preparation is trivial: keep the policy document, a cancelled cheque of the registered account and current KYC ready a month before the due date, and the payout arrives on time.

Why claims actually get rejected

• Non-disclosure at proposal stage. The undisclosed thyroid diagnosis, the old hospitalisation — insurers verify against records at claim time, and the contest can end in repudiation. Declare everything; our pre-existing disease waiting period explainer covers what counts as pre-existing.
• Waiting periods. Claims inside the 30-day initial wait or the pre-existing window are payable only after the clock matures — timing, not bad faith.
• Exclusions. The procedure sits on a specific-procedure list, or the room breached the cap, or the treatment is a standing exclusion.
• Documents. A missing discharge summary or an unattested bill stalls a reimbursement claim; the circular forbids rejecting a claim merely for want of documents, but the clock does not run until the file is complete.
• Lapse. The event date fell inside a lapsed policy period, past the grace period — 15 days for monthly modes, 30 for others.

No claim shall be rejected or closed for want of documents or for delayed intimation of claim. Source: IRDAI Master Circular on Protection of Policyholders' Interests, 2024.

That single line does real work: an insurer cannot quietly shut your file because one bill is pending or you intimated a week late. It must ask, in writing, for what is missing.

The escalation ladder

Work it in order. One: the insurer's own grievance channel — acknowledgement immediately, resolution within 14 days with reasons for any rejection (Source: IRDAI Master Circular on Protection of Policyholders' Interests, 2024). Two: the Bima Bharosa portal, IRDAI's complaint platform at bimabharosa.irdai.gov.in, into which insurers must mirror their grievance databases in real time. Three: the Insurance Ombudsman — free of cost, no lawyer permitted, complaint due within one year of the insurer's rejection or one month after the insurer's silence, for claims up to Rs 50 lakh. The Ombudsman passes an award within three months of receiving the complete complaint; the award binds the insurer, which must pay within 30 days or face a Rs 5,000-per-day penalty (Source: Insurance Ombudsman Rules, 2017 as amended, per the Council for Insurance Ombudsmans, cioins.co.in; and IRDAI Master Circular on Protection of Policyholders' Interests, 2024, Ombudsman awards section).

Run the ladder with dates, because each rung has one. Reimbursement documents complete on 10 May: the 15-day clock ends 25 May. No settlement by 27 May means a written complaint to the insurer — acknowledgement immediate, resolution due by 10 June. Silence or refusal on 11 June means the Bima Bharosa complaint that same week, and an Ombudsman filing within one month of the insurer's silence or one year of its rejection. The ladder only works if you write the dates down.

Prepare before you need it

• Tell the nominee the policy exists: which insurer, roughly what cover, which folder the document lives in. Unclaimed policy money with insurers runs into tens of thousands of crores mostly because nominees never knew.
• Keep one folder — physical or cloud — with the policy, premium receipts, and ID proofs, and tell someone where it is.
• Keep the bank account registered with the insurer active; payouts go only to the registered account.
• For health, save the network-hospital list and the insurer's 24/7 assistance number in your phone today.
• At every renewal, update nominations. A claim routed through legal-heirship paperwork adds months.
• If your only cover is an employer group scheme, start a personal policy — group cover dies with the job, and the waiting-period and moratorium arguments for continuity are in our pre-existing disease explainer.

The claim process rewards the boring half-hour of preparation far more than it rewards any amount of post-event persistence. The timelines above are your leverage; the documents folder is your speed.

This is educational content, not investment advice. Consult a SEBI-registered advisor for decisions specific to your situation.