Cashless Health Insurance Approval Delayed by TPA or Hospital? Do This

Who this guide is for

This guide is for anyone who is currently admitted to a network hospital — or is preparing to be admitted — and whose cashless health insurance approval has been delayed, queried, or simply ignored by the TPA or insurer. It is also useful for family members managing the paperwork on behalf of a patient.

You will find this guide particularly useful if:

• The hospital's insurance desk tells you the TPA has not responded to the pre-authorisation request.
• The TPA has asked for documents and the hospital says it has already sent them.
• Discharge is being held up because the final authorisation amount has not arrived.
• You were admitted as an emergency and are now being asked to pay out of pocket because the cashless process was not initiated in time.
• You have already been discharged after paying the bill yourself, and now want to claim reimbursement — but are worried about missing the deadline.

This guide covers policies from both private health insurers (such as Star Health, HDFC ERGO, ICICI Lombard, Niva Bupa, Care Health, and others) and public-sector general insurers (New India Assurance, National Insurance, Oriental Insurance, United India Insurance). The escalation process is the same for both; the RTI angle differs — see the RTI section below.

For a deeper guide on what to do when cashless is outright denied, read our companion article on cashless claim denial at the hospital.

What you can do this weekend

Friday evening

If you or a family member is in hospital and cashless approval has stalled, do these things before the day ends:

• Ask the hospital insurance desk for a written note (even a WhatsApp message) confirming the date and time the pre-authorisation request was sent to the TPA, and what — if anything — is still pending from the hospital's side.
• Locate your health card or policy document. Write down: your policy number, the TPA name, the TPA helpline number, and your insurer's toll-free customer care number.
• Call the TPA helpline and note the reference number of your complaint call. Ask them to send you a written update — SMS, email, or a message on the insurer's app.
• If the TPA helpline is unreachable after hours, call your insurer's 24-hour emergency helpline. Many insurers have a separate number for hospital emergencies — check your policy schedule or the insurer's website.

Saturday

• If you have not received a written response from the TPA or insurer, send a short email to the insurer's Grievance Redressal Officer. Use the template in the complaint template section below. The GRO email address is on your policy document; if not, it is on the insurer's website under "Grievance" or "Customer Service".
• Ask the hospital to share a copy of every query it received from the TPA, and its replies. Keep these safe — you will need them if you escalate.
• If the hospital is holding you back at discharge because the final authorisation amount has not come and you are able to pay, consider paying the bill yourself and switching to a reimbursement claim. Collect every original document before you leave. Most policies require reimbursement documents within 30 days of discharge — confirm the exact period in your policy.

Sunday

• If the insurer has not resolved the issue and you are still in hospital, register a complaint on IRDAI's Bima Bharosa portal. The portal works seven days a week. Upload your complaint, the GRO email you sent, and any correspondence.
• Call IRDAI's toll-free Grievance Call Centre on 155255 (or 1800-4254-732), available 8 AM to 8 PM Monday to Saturday. They can flag your complaint directly to the insurer.
• If discharge is genuinely being blocked and you face a medical or financial emergency, speak to the hospital's patient relations manager or medical superintendent — not just the insurance desk staff — and ask them to escalate internally as well.

Documents and evidence checklist

Collect and organise these before or during discharge. Taking clear photographs on your phone is enough if you cannot get photocopies immediately.

Step-by-step action plan

Step 1 — Understand exactly what is blocking the approval

Before making any calls, go to the hospital's insurance or TPA help desk and ask one direct question: "What is the exact reason the pre-authorisation has not been issued, and whose court is it in right now — ours or the TPA's?"

The delay usually falls into one of three categories:

• The hospital has not yet sent the complete pre-authorisation request. In this case, push the hospital desk — not the TPA — to send it immediately with all required documents.
• The TPA has raised a medical query and the hospital has not yet replied. Ask the hospital to reply urgently and give you a copy of their response.
• The TPA or insurer has received the complete request but has not responded. This is the scenario covered by the IRDAI one-hour rule. Move to Step 2 immediately.

Step 2 — Call the TPA directly (emergency desk script)

Most TPAs have a 24-hour helpline for hospitals and policyholders. The number is printed on your health card. When you call, say something like this:

"My name is [your name]. My policy number is [number] with [insurer name]. I am a patient admitted at [hospital name] since [date]. The hospital submitted the pre-authorisation request on [date and time, if known] — reference number [if available]. It has now been more than [X hours]. Under IRDAI's current rules, you are required to issue pre-authorisation within one hour of receiving a complete request. Please tell me the current status and when I will get written authorisation. I am logging this call — please give me your name and employee ID."

Write down: the TPA agent's name, your call reference number, and the time of the call. Ask them to send a written update to the hospital desk or to your registered mobile / email.

Step 3 — Call your insurer's toll-free number

Simultaneously (or right after), call your insurer's toll-free customer care number — printed on your health card, policy document, or the insurer's website. Log a verbal complaint about the delay. The insurer owns the TPA relationship and can instruct the TPA to act. Ask the agent to raise a formal complaint ticket and give you the ticket number.

Step 4 — Submit a written complaint to the Grievance Redressal Officer

Every insurer must have a Grievance Redressal Officer (GRO) and publish that person's name, email, and phone number on the policy document and on the insurer's website. Send an email to the GRO with:

• Your policy number, claim reference, and hospital details.
• The timeline — when you were admitted, when the hospital sent the pre-authorisation request, what the TPA has said so far.
• A clear ask: issue the pre-authorisation or the discharge authorisation within 24 hours, or explain in writing why the request is being held.
• All supporting documents attached (pre-auth request copy, hospital correspondence with TPA).

Use the TPA email template below as a starting point. The insurer is required to acknowledge your complaint and work toward resolution — check your policy or the insurer's website for their stated grievance turnaround.

Step 5 — Decide whether to switch to reimbursement

If the delay is causing hardship — if you are stuck at discharge, or if the treatment is urgent and cannot wait — consider paying the hospital bill yourself and filing a reimbursement claim. This is always your right, even on a network hospital cashless policy. Collect every original document before you leave, and submit the claim well within the deadline in your policy (typically 30 days from discharge, but confirm in your own policy schedule). For more on what to do when the cashless route fails entirely, see our guide on cashless claim denial at hospital.

Step 6 — File on IRDAI Bima Bharosa

If the insurer does not resolve your complaint within its own stated timeframe, register a grievance on the IRDAI Bima Bharosa portal. The process takes about 10 minutes. You will need your policy number, insurer name, and a description of the complaint. Upload your documents and GRO correspondence. IRDAI requires insurers to resolve Bima Bharosa complaints within 14 days. You can track your complaint status on the same portal.

You can also call IRDAI's Grievance Call Centre on 155255 or email [email protected] to register your grievance by phone or email if you cannot access the portal.

Step 7 — Insurance Ombudsman or Consumer Forum

If Bima Bharosa does not produce a resolution, your next option is the Insurance Ombudsman. There are offices in 17 cities across India. The process is free, you do not need a lawyer, and the ombudsman can issue a binding award. See our full guide on how to complain to the Insurance Ombudsman. For large-value or systemic matters, you may also approach a Consumer Disputes Redressal Forum.

Escalation ladder

Copy-paste complaint template

Replace the text in square brackets with your own details before sending.

When RTI can help

The Right to Information Act, 2005 applies to public authorities. In the context of health insurance cashless delays, RTI can help in the following situations:

If your insurer is a public-sector general insurer

The four public-sector general insurers — New India Assurance, National Insurance Company, Oriental Insurance Company, and United India Insurance Company — are government-owned companies and are public authorities under the RTI Act. You can send an RTI application to their Central Public Information Officer (CPIO) to ask for:

• The status of your claim and the reasons for any delay, in writing.
• Copies of internal guidelines or circulars issued to their TPAs about claim processing timelines.
• The complaint disposal statistics for their grievance cells.

Each of these companies has RTI compliance pages on their official websites where CPIO contact details are published. RTI applications must be submitted in hard copy (email filings are not accepted) with the prescribed fee, as per each company's RTI notices. See our guide on how to file an RTI application for the general process, and how to file a first appeal if the CPIO does not respond.

If the hospital is a government or public hospital

Public hospitals (government-run district hospitals, AIIMS, ESI hospitals, and similar institutions) are public authorities. If a government hospital's insurance desk mishandled your pre-authorisation request or failed to send documents to the TPA on time, you can file an RTI with the hospital to get the internal records of what was sent and when.

For IRDAI records

IRDAI is a statutory regulator and a public authority. You can file an RTI with IRDAI to obtain aggregate complaint statistics, insurer compliance data, or information about the regulatory framework that applies to your situation. RTI applications to IRDAI are filed with their CPIO in Hyderabad.

When RTI will not help

Private health insurers are not public authorities under the RTI Act. You cannot send an RTI application to Star Health, HDFC ERGO, ICICI Lombard, Niva Bupa, Care Health, Aditya Birla Health Insurance, or any other private insurer. RTI applications sent to private insurers will be rejected or simply ignored.

Private TPAs are also not public authorities. Medi Assist, Paramount, HealthIndia, MD India, Raksha TPA, and similar private TPAs cannot be compelled to respond to RTI applications.

For disputes with private insurers and private TPAs, your remedies are the insurer's GRO, IRDAI Bima Bharosa, the Insurance Ombudsman, and the Consumer Forum — all of which are described in this guide. See our companion guide on how to file an insurance complaint with IRDAI for the full detail.

For those with public-sector insurer policies, RTI is a useful parallel tool — not a replacement for the grievance route. Filing a formal grievance with the GRO and Bima Bharosa will usually be faster.

Common mistakes to avoid

• Only talking to the hospital desk, not the TPA directly. Hospital desk staff pass messages between you and the TPA but have no authority to compel the TPA. Call the TPA helpline yourself and create a paper trail.
• Assuming the TPA and the insurer are the same entity. The TPA processes the paperwork; the insurer makes the final decision and is ultimately responsible for delay penalties. Always escalate to the insurer if the TPA is unresponsive — the insurer controls the TPA.
• Not getting anything in writing. A verbal approval from the TPA over the phone is not enough. Ask for written confirmation — an email, an app notification, or a printed letter from the hospital desk. Without something in writing, you cannot prove what was or was not approved.
• Leaving the hospital without collecting original documents. If you pay out of pocket and plan to claim reimbursement, you need original bills, discharge summary, and reports. Hospitals are not always cooperative after you have settled the bill. Collect everything before you walk out.
• Missing the reimbursement submission deadline. Most policies require reimbursement claim documents within 30 days of discharge. Some are stricter. Check your specific policy document — the clock starts on the date of discharge, not the date you file a complaint with the insurer.
• Going straight to the ombudsman without first approaching the insurer. The Insurance Ombudsman requires you to have already approached your insurer and either received no response within 30 days or received an unsatisfactory one. Skipping the insurer step makes your ombudsman complaint procedurally weak.
• Sending an RTI application to a private insurer. The RTI Act does not apply to private insurance companies. Sending such an application wastes time you could spend on the effective remedies — the GRO, Bima Bharosa, or the ombudsman. See the RTI section above for what RTI can actually help with.
• Not mentioning the IRDAI timeline in your complaint. Insurers respond faster when a written complaint explicitly cites the IRDAI Master Circular requirement. Use the template above, which already includes this reference.