1 November 2026 • 5 min read
This sheet is for product managers and founders who build claims journeys, TPA integrations or insurer dashboards in India. It covers the claims terms that the RBI, SEBI and IRDAI glossary does not: the ratio insurers report, the authorisation and settlement clocks, repudiation, surveyors and the Ombudsman. Cashless facility, TPA, co-payment and deductible are defined there. The terms below come from IRDAI's Annual Report 2024-25, its Master Circular on Health Insurance Business (Version 1, 29 May 2024) and IRDAI pages. The master circular says it is reviewed every year; we found no later version on the IRDAI pages we opened, so check the IRDAI site for a newer one.
| Term | Meaning |
|---|---|
| Incurred claims ratio (ICR) | Net incurred claims divided by net earned premium. For 2024-25 IRDAI gives 82.88 per cent for the non-life industry, against 82.52 per cent the year before. For health business of general and health insurers (excluding personal accident and travel) it gives 86.98 per cent, down from 88.15 per cent. |
| Why two health figures differ | The same report shows a second health figure, 85.34 per cent for 2024-25, in a segment table. The table titles differ, and the note under the 86.98 per cent table excludes personal accident and travel business. Quote the table you used. |
| Claims settled, repudiated, pending | For 2024-25 insurers settled about 87 per cent of health claims registered, repudiated about 8 per cent, and about 5 per cent were pending on 31 March 2025. |
| Mode of settlement | By number, 58 per cent of health claims were settled cashless and 41 per cent through reimbursement. By amount, 66.35 per cent was paid cashless. |
| Settled through TPAs | By number, 69 per cent of health claims were settled through TPAs and 31 per cent in-house. |
| Term | Meaning |
|---|---|
| Pre-authorisation (cashless) | The insurer decides on a cashless request immediately and in no case later than one hour from receiving it. Insurers must also give pre-authorisation to the policyholder digitally. |
| Final authorisation at discharge | The insurer grants it within three hours of the hospital's discharge request. If it is later, the extra amount the hospital charges is borne by the insurer from the shareholders' fund. |
| Reimbursement claim | The policyholder pays the hospital and claims the money back. The master circular says insurers should keep reimbursement to a bare minimum and to exceptional circumstances, because they should aim for 100 per cent cashless settlement. IRDAI's health FAQ lists 15 days as the turnaround for claims other than cashless. |
| Last necessary document | IRDAI's FAQ on health insurance regulations, citing the 2016 and 2017 regulations, says the insurer must settle or reject within thirty days of this document. Ordinarily no document outside the policy terms is "necessary" unless fraud is suspected, and all documents must be asked for at one time. |
| Investigation window | Where the insurer thinks a claim needs investigation, it must finish within 30 days of the last necessary document and settle within 45 days. Late payment carries interest at 2% above the bank rate. |
The 15-day and 30-day figures sit on two different IRDAI pages. Ask your insurer partner which one its contract and the current circular apply to, and build the clock from that.
| Term | Meaning |
|---|---|
| Repudiation | A refusal to pay. The master circular says no claim can be repudiated without approval of the Product Management Committee (PMC) or its three-member sub-group, the Claims Review Committee (CRC). |
| Partial disallowance | If a claim is repudiated or disallowed in part, details go to the claimant with full reference to the specific policy terms and conditions. |
| Rejected versus repudiated (life) | IRDAI's annual report footnotes: rejected claims cannot be considered due to policy terms; repudiated claims cannot be considered under section 45 of the Insurance Act, 1938. Do not use the two words as synonyms in life data. |
| Documents from hospital | After the claim is intimated, insurers and TPAs collect the required documents from hospitals. The policyholder is not required to submit them. |
| Insurance Ombudsman | The escalation route. An insurer's reply to a grievance must include the Ombudsman's contact details. It must comply with an award within 30 days of receiving it, or pay ₹5,000 a day to the complainant. |
| Multiple policies | For indemnity policies the policyholder picks the primary insurer, who coordinates with other insurers on any balance. For benefit-based policies the holder can claim from all insurers. |
| Term | Meaning |
|---|---|
| TPA payment rule | A TPA's remuneration must not depend on the ICR of the policies it serves. Insurers pay TPAs only after services are delivered, and can claw back charges based on customer feedback, passing the clawed-back amount to the customer. |
| NHCX | National Health Claims Exchange. The master circular asks insurers and insurance councils to try to onboard hospitals and healthcare providers on it for faster payment and settlement. |
| Surveyor and loss assessor | A licensed professional who assesses a loss in general insurance claims, such as motor or fire. IRDAI's handbook says an insurer must appoint one where the estimated loss is above ₹50,000 for motor or above ₹1,00,000 for other classes. |
| Survey report time | The handbook says the report is due within 30 days of appointment. Beyond that the surveyor must seek an extension from the insurer, and the limit cannot exceed 6 months. The insurer can ask for an additional report within 15 days of the original. |
The handbook is undated and also cites the 2002 policyholder regulations, so confirm survey rules against the current regulations before you hard-code them.
It only says what share of earned premium went to claims. It is a result for an insurer's book, not a measure of how well one claim was handled. IRDAI's circular says a TPA's pay must not depend on it.
They use different scopes. The 86.98 per cent figure excludes personal accident and travel business. Check the table note before using a number.
No. Final authorisation and repudiation are separate steps. Any repudiation still needs CRC approval and reasons tied to the policy terms.
One hour for pre-authorisation and three hours for discharge authorisation, per the 2024 master circular.
Check current IRDAI circulars and take advice from a professional before you hard-code claim rules into a product.
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