FAQ
Clear, clean answers from claim specialists — on rejection, documentation, room rent, sub-limits, IRDAI rules and ClaimTrue services.
A. About health insurance claims
- Why are health insurance claims rejected in India?
- Claims are rejected for three broad reasons: documentation errors such as missing prescriptions or incomplete forms; policy violations such as room-rent breach, undisclosed pre-existing conditions or treatment during a waiting period; and coverage gaps such as sub-limits, exclusions and non-payable expenses. Roughly 11% of rejections are purely documentation-related — these are entirely preventable with a pre-submission audit.
- How can I avoid claim rejection?
- Read your policy fully, declare pre-existing conditions accurately, stay within your room-rent limit, collect every required document during hospitalisation rather than after discharge, and run a pre-submission audit before the file reaches the TPA. A pre-submission audit alone removes the majority of avoidable rejections.
- What is proportionate deduction?
- If your policy allows a certain room rent (say ₹4,000 a day) and you take a higher-category room (say ₹6,000), the insurer can reduce your entire claim in proportion — ICU, surgery, medicines, everything — typically by 30 to 50%. This is why the room-rent decision at admission matters far more than most patients realise.
- What documents are needed for a reimbursement claim?
- A standard file includes the signed claim form, the original hospital bill with itemised breakup, discharge summary, investigation reports, prescriptions, pharmacy invoices, indoor case papers, doctor's certificate, ID and KYC, cancelled cheque for NEFT, ambulance receipt where applicable and an MLC copy in the case of injury or accident. Pre and post-hospitalisation require separate prescription-backed bills within the policy window.
- How long does a claim take in India?
- Cashless approvals at network hospitals typically take 4 to 6 hours. Reimbursement claims take 15 to 30 days from the submission of complete documents. Incomplete files or insurer queries can extend the timeline to 60 to 90 days. A pre-audit reduces query cycles meaningfully.
- What is a non-payable item in a hospital bill?
- Items such as gloves, masks, syringes, gauze, registration charges, attendant and food charges, telephone, television and toiletries are classified as non-payable by IRDAI. These can be 7 to 12% of a typical bill and are routinely absorbed by the patient unless the bill is verified line by line.
- Can a rejected claim be reopened?
- Yes. A rejected claim can be resubmitted with corrected documents, escalated to the insurer's grievance officer, and finally escalated to the IRDAI Insurance Ombudsman. Many rejections — especially those with technical grounds — are reversible.
- What is a TPA?
- A Third Party Administrator (TPA) processes claims on behalf of an insurer. They verify documents, coordinate with hospitals, calculate the payable amount and issue the final settlement letter. Most claim disputes happen at the TPA stage.
- Are pre and post-hospitalisation expenses covered?
- Yes, within defined windows — typically 30 to 60 days before hospitalisation and 60 to 180 days after, depending on your policy. Prescription-backed bills for tests, medicines and follow-up consultations must be preserved.
- How does IRDAI protect policyholders?
- IRDAI publishes a standardised non-payable list, mandates grievance-resolution timelines, regulates premium increases and runs the Insurance Ombudsman for unresolved disputes. Policyholders can file ombudsman complaints free of charge for claims up to ₹50 lakh.
B. About ClaimTrue
- What does ClaimTrue do?
- We decode your policy, audit your claim before submission, verify your hospital bill line by line and defend you if a claim is rejected. We do not sell insurance and earn no commission from any insurer.
- Is ClaimTrue an insurance company?
- No. ClaimTrue is an independent claim advocacy and documentation support platform. Our independence is the foundation of our service.
- What does the ₹599 / year subscription include?
- The ₹599 plan includes free policy buying/upgrading assistance for mis-selling prevention, a complete policy decode within 24 hours, pre-submission claim audits, documentation completeness checks for 15+ documents, a digital document vault, and special assistance for senior citizens. Members also get a reduced claim processing fee of 7% (instead of 10%). Priority rejection defence is available at 20% of the recovered amount + GST.
- How is ClaimTrue different from an insurance broker?
- Brokers earn commission from insurers; their incentive is to sell policies. ClaimTrue earns nothing from insurers and is compensated only by subscribers and on successful claim recovery. We work before submission to prevent rejection, not after to commiserate.
- Can you help if my claim has already been rejected?
- Yes. Our rejection handling service covers full analysis, document rectification, representation drafting, resubmission and — where required — escalation to the grievance officer and IRDAI Ombudsman. The fee is 20% of the amount recovered plus GST. No recovery, no fee.
- Do I need to be a subscriber to use rejection handling?
- No. Rejection handling is available to both subscribers and non-subscribers at the same recovery-linked fee. Subscribers are placed in a priority queue and receive a free pre-audit on the resubmission file.
- Is my data safe?
- Yes. All policy, medical and personal documents are stored in encrypted cloud storage with access controls and audit logging. We are ISO 27001 certified and do not share data with insurers, hospitals or any third party without your explicit consent.
- Can I cancel my subscription?
- Yes. The annual membership is non-refundable once activated, but simply ends at year-end if you choose not to renew. There is no auto-renewal trap.
- Which insurers are supported?
- All major Indian health insurers and TPAs — public and private — across hospitalisation, day-care procedures, pre and post-hospitalisation and reimbursement categories.
- Do you offer senior citizen support?
- Yes. Phone-based walkthroughs in English, Hindi and major regional languages; doorstep document collection in major cities; coordination with hospital TPA desks on behalf of the family; and priority in rejection defence cases.
C. Pricing & billing
- Is there a free option?
- The Risk Assessment is free — no login, no card, no subscription. The full ClaimTrue protection layer starts at ₹599 / year.
- Are there hidden fees?
- No. The subscription fee is the only fixed cost. Per-claim processing and rejection handling are disclosed clearly up front, and rejection handling is billed only on recovered amounts.
- How is the subscription billed?
- Personal Protection Plan is billed annually. Hospital Starter and Enterprise plans are billed monthly. All prices are in INR and subject to applicable taxes.
- What payment methods are accepted?
- UPI, major credit and debit cards, net banking and wallets. Card details are not stored on our servers.
- Can I get a refund if I did not file a claim during the year?
- No — the annual membership covers unlimited advisory, audit and protection access throughout the year, regardless of how many claims are filed. Many subscribers use the policy decode and risk audit before ever filing a claim.
Still have a question?
Email info@claimtrue.in or call us Mon–Sat, 9 AM – 6 PM IST.