T10 · 9 documents tagged to this reason
Claim neither paid nor rejected for months
Silence is not a neutral state under the regulations — it's a breach with a price. IRDAI sets specific clocks for cashless decisions, discharge authorisation and final settlement, and missing them earns you interest independent of whether the underlying claim itself was even in question.
How insurers word it
- Claim under process / under review
- Awaiting additional information from the hospital
- No response for weeks despite repeated follow-up
- Claim closed after full and final discharge voucher
Arguments that have beaten this
C-T10-1
Regulatory clocks earn interest when missed
Insurers must decide claims within set regulatory timelines: cashless authorization "immediately but not more than one hour" of the request; final discharge authorisation within three hours of the hospital's request, with any resulting extra hospital charges borne by the insurer's own funds, not yours; portability decisions within 5 days. Delay beyond these clocks earns interest and is itself evidence of service deficiency.
Source
Master Circular IRDAI/HLT/CIR/PRO/84/5/2024: para 15(b) (one-hour cashless decision), para 16(a),(b) (three-hour discharge, delay charges on the insurer's shareholder funds), para 12(c) (5-day portability decision). OA-022: 8% simple interest awarded for a timeline breach under the predecessor regulation.
Where this argument fails
You have already signed a full-and-final discharge voucher — that can bar reopening the claim, so get advice before signing one while a dispute is live.
We publish the losing side too. An appeal built on an argument that does not fit your facts wastes the one year you have.
It's been two months and the insurer still hasn't paid or rejected my claim. What can I do?
This delay itself has a cost to the insurer. Regulatory timelines apply throughout the claims process, and a breach has previously earned a policyholder 8% simple interest in addition to the claim amount. Put your grievance in writing to the insurer's GRO first — the clock and the paper trail both work for you.
I signed a discharge voucher accepting a lower amount because I needed the money urgently. Can I still reopen it?
This is genuinely hard. A signed full-and-final discharge voucher has been treated as a bar to reopening a claim in our corpus. If you haven't signed one yet while a dispute is live, don't — get the shortfall in writing as a dispute first. If you already have, get advice on the specific circumstances of the signing before assuming the door is fully closed.
Is this the reason on your letter?
Ladai will read your specific letter and policy and tell you which of these arguments actually reaches your facts — and how strong that makes your case.
Get your verdict on this