For health insurance policyholders, understanding the rules insurers must follow during the claim and grievance process can be extremely useful. These protections become particularly important when cashless approval is delayed, discharge gets held up, an earlier medical disclosure is questioned, or a complaint is taken to the Insurance Ombudsman.
Knowing the prescribed timelines and protections can help policyholders track their claims and take appropriate action when there is an unnecessary delay.
Here are five IRDAI-mandated claim rights that every policyholder should be aware of.
1. Cashless pre-authorisation must be decided within one hour
When a hospital submits a cashless pre-authorisation request to an insurer, the insurer is required to make a decision within one hour of receiving the request. This does not mean that every request must be approved, as the claim must still satisfy the terms and conditions of the policy.
The one-hour timeline is important when a cashless request remains pending and the patient or family is repeatedly following up with the hospital. Policyholders should ask the hospital’s insurance desk when the request was received or acknowledged by the insurer.
If an hour has elapsed without a decision, the policyholder can use this prescribed timeline to follow up with the insurer and escalate the matter if necessary.
2. Final discharge authorisation must come within three hours
Claim-related delays can continue even after treatment has been completed. A doctor may have cleared the patient for discharge, while the hospital is still waiting for the insurer’s final authorisation.
IRDAI requires insurers to issue final discharge authorisation within three hours of receiving the discharge authorisation request from the hospital.
Importantly, a patient should not have to remain in the hospital simply because of a delay by the insurer. If the insurer takes more than three hours and the hospital levies additional charges because of that delay, such expenses have to be paid by the insurer from its shareholders’ fund.
3. Five years of continuous coverage provides moratorium protection
Questions over non-disclosure or misrepresentation are a frequent source of disputes between policyholders and insurers. However, insurers cannot keep challenging old disclosures indefinitely.
From April 1, 2024, the moratorium period was reduced from 96 months to 60 continuous months.
After completing 60 continuous months of uninterrupted coverage, a policy and claims generally cannot be questioned on grounds of non-disclosure or misrepresentation, except where fraud has been established.
4. Insurers have time limits for responding to Ombudsman
If a policyholder’s grievance remains unresolved through the insurer’s internal grievance process, the dispute may be taken to the Insurance Ombudsman. The process also prescribes timelines for insurers to provide their response and supporting documents.
In a circular issued on July 23, 2026, IRDAI specified timelines for insurers responding to Ombudsman proceedings.
After receiving a notice from the Insurance Ombudsman, an insurer must submit its Self-Contained Note, along with all relevant documents, within seven days.
If the Ombudsman later requests additional information or documents, the insurer gets three days to submit them.
5. Insurers must comply with an Ombudsman award within 30 days
An order in favour of a policyholder from the Insurance Ombudsman does not end the process. The insurer is required to implement the award within the prescribed period.
An insurer must comply with the Ombudsman award within 30 days of receiving it. If it fails to implement the award within this period, the complainant is entitled to ₹5,000 for every day of delay, in addition to the applicable penal interest.
However, this provision does not apply where the insurer appeals against the award within 30 days. In such a situation, the award is formally being challenged rather than simply ignored, and the policyholder must be informed about the appeal.