Unified Patient Claim Journey

A standardised map of the Indian health insurance claim process. From initial symptoms to final settlement.

• Patient: Policyholder
• Doctor: Clinical owner
• Hospital: Service provider
• Managed Care: Support and coordination
• TPA: Claims administrator
• Insurer: Financial risk bearer

1 Common entry — Diagnosis

Patient + Doctor

Initial consultation (OPD)

Patient presents symptoms. Doctor performs clinical assessment — history, vitals, preliminary examination.

Owner: Doctor Executes: Patient, Doctor Prescription

Hospital Lab + Doctor

Diagnostic workup

Lab tests, imaging, pathology performed at hospital. Results interpreted by treating doctor to confirm diagnosis.

Owner: Doctor Executes: Lab, Patient (OPD cost) Lab reports Imaging results

Doctor

Admission advice

Clinical decision that in-patient hospitalisation is medically necessary. Formal admission advice note issued — the trigger document for any claim.

Owner: Doctor Admission advice note

Decision junction — Hospital admission desk

The path splits based on network status and policy type. This determines who pays upfront and how the claim flows.

1. Is the hospital in the insurer's network?
2. Does the policy support cashless facility?
3. Does the patient's ID match policy records?

2 Parallel settlement paths

Path A — Cashless

A.1

Pre-authorisation filing

Hospital admin submits pre-auth request to TPA with patient details, diagnosis, estimated cost, and admission advice.

Hospital admin Owner: TPA Pre-auth form

A.2

Query / deficiency loop

TPA may raise queries — missing documents, unclear diagnosis codes, or additional clinical justification needed. Hospital and doctor respond.

Doctor consulted Hospital admin

A.3

Pre-auth approval

TPA sanctions initial amount. Approval letter issued with sanctioned amount and conditions.

Owner: TPA Approval letter

A.4

In-patient treatment

Treatment proceeds. Doctor manages clinical care. TPA monitors via interim updates from hospital.

Owner: Doctor

A.5

Enhancement request

If treatment cost exceeds sanctioned amount, hospital files enhancement with TPA for additional approval.

Hospital admin Owner: TPA Enhancement form

Path B — Reimbursement

B.1

Upfront payment

Patient pays full estimated cost or deposit out-of-pocket at the time of admission.

Patient Payment receipt

B.2

In-patient treatment

Treatment proceeds. No TPA involvement during stay. Hospital bills directly to patient.

Owner: Doctor

B.3

Records collection

Patient collects all original medical documents — bills, discharge summary, investigation reports, payment receipts.

Patient Owner: Hospital Original bills

B.4

Claim submission to TPA

Patient or managed care provider compiles and submits reimbursement claim with all originals within policy deadline (15–30 days).

Patient Managed care Claim form

B.5

Query / deficiency loop

TPA may request additional documents, clarifications, or investigation before processing.

Patient Owner: TPA

Paths converge

3 Post-discharge and settlement

Doctor + Hospital

Discharge summary

Doctor issues clinical closure — diagnosis, treatment administered, medications, follow-up instructions. Hospital admin finalises billing.

Owner: Doctor Discharge summary Final bill

TPA + Insurer

Claim adjudication

TPA reviews all documents, verifies medical necessity, checks policy terms, sub-limits, exclusions, and co-pay clauses. Recommends settlement amount to insurer.

Owner: TPA Insurer (escalations)

Patient

Post-hospitalisation recovery

Follow-up visits, pharmacy, and rehab within policy window (typically 60–90 days post-discharge). These expenses are separately claimable.

Patient Managed care Follow-up bills

Insurer

Final settlement

Insurer disburses approved amount — to hospital (cashless) or directly to patient's bank account (reimbursement). Settlement letter issued.

Owner: Insurer Insurer finance Settlement letter

Responsibility ownership matrix

Who owns, executes, is consulted, and is informed at each step across both claim paths.

Step	Patient	Doctor	Hospital	Managed Care	TPA / Insurer
OPD consultation	Executes	Owner	Informed	Informed	—
Diagnostics	Executes	Owner	Executes	—	—
Admission advice	Consent	Owner	Informed	Informed	—
Pre-auth filingCashless	Informed	Med data	Executes	Coord	Owner
EnhancementCashless	Informed	Justifies	Executes	—	Owner
Upfront paymentReimbursement	Executes	—	Informed	—	—
Claim submissionReimbursement	Executes	—	—	Assists	Owner
In-patient treatment	Informed	Owner	Executes	—	Monitors
Discharge summary	Receives	Owner	Executes	—	Receives
Claim adjudication	Informed	—	Informed	—	Owner
Post-hosp recovery	Executes	Consulted	—	Assists	—
Final settlement	Informed	—	Informed	—	Owner