How to File a Surgery Claim in Health Insurance: A Complete Guide

10 min read Posted on 10july 2025

Undergoing surgery is challenging enough without the added stress of managing insurance paperwork. Understanding how to navigate the health insurance claim process can ease this burden significantly. Whether your surgery was planned or an emergency.

A structured approach to filing your claim ensures smoother processing and timely reimbursement. From organising hospital bills to submitting the correct documents to the right channels, this guide clearly outlines each step for a surgery claim in health insurance. It aims to simplify the process and help you avoid common pitfalls, keeping the focus on what matters most: your recovery.

Pre-Authorisation Process (For Cashless Claims)

If you're heading for a planned surgery and want to use your insurance for a cashless claim, here's what you need to get right from the very beginning. Follow this guide closely so you don’t end up paying out of pocket or chasing emails later. This is known as the pre-authorisation process in India, especially for planned surgeries where early intimation helps avoid claim denials.

1. Use the Updated Pre-Authorisation Form      Always pick the latest form issued by your TPA. Old ones often miss important sections that are now made mandatory.
2. Fill in Every Blank — Clearly and Completely      Avoid scribbles and shorthand. Write the patient’s condition and procedure names in full — no abbreviations.
3. Don’t Forget the Signature      Get the patient’s or the family member’s signature at the exact place marked in the form. Skipping this small detail can bring the process to a halt.
4. Be Transparent About the Patient’s Health History      Mention everything — even pre-existing conditions or alcohol habits. Leaving things out can result in denial later.
5. Stick to the Agreed Pricing      Use the rate list you’ve already shared with the TPA. Charging beyond this list leads to unnecessary queries.
6. New Surgery? New Price List Required      If you’re performing a newly introduced procedure, send its pricing details immediately to the TPA’s network team.
7. Send the Form a Few Days Before Admission      If the surgery isn’t an emergency, send the request in advance. This avoids last-minute hiccups. This is especially important for a planned hospitalisation claim.
8. Check the Approval Status      Follow up with the TPA’s pre-auth team and ask for updates if you haven’t heard back.  

Documents for Surgical Claim

Submit these with the pre-authorisation request, these are the core documents for surgical claim processing:

• Patient’s ID proof
• Complete diagnosis documents
• Proposed treatment/surgery details
• Estimated cost
• Doctor’s notes

After You Get the Approval

Don’t skim through the approval. Pay attention to:

• Room rent cap
• Co-pay amount
• Surgery-specific coverage limit
• Any clause that limits coverage to specific hospitals, dates, or conditions  

Before Discharge: Tie Up All Loose Ends

• Get the patient’s signature on:
  • Discharge summary
  • Final hospital bill
  • Voucher part of the approval form
• Ask the patient to fill out and sign the claim form
• Collect the co-pay (if applicable) and give a separate receipt. Missing this can void the entire claim.
• Gather and keep:
  • Cashless approval copy
  • operation notes
  • Hospital’s breakup bill + final bill
  • eceipt of any payment made by the patient
  • Investigation reports
  • Photo ID of the patient  

Claim Submission

• Submit all documents to the TPA by the next working day
• Send them through a reliable office courier, three times a week
• Keep a copy of every file you submit
• Take a stamped receipt for each individual file, not in bulk

Some Special Points to Keep in Mind

• For maternity claims:
  • No coverage if the policyholder already has two or more living children.
  • Charges related to regular newborn care aren’t covered.
• If the patient is HIV positive and this wasn’t disclosed earlier, the approval becomes void.
• Non-covered items must be billed directly to the patient before discharge. Check the list of such items on the TPA’s official site.
• A field executive may visit to collect papers or verify the case — be cooperative.

Surgery Cashless vs Reimbursement

Check out this overview of surgery cashless vs reimbursement

Common Reasons for Delay or Rejection

Health insurance claims don’t have to be a headache. Here’s how you can keep things on track:

1. Read your policy thoroughly: The fine print holds the key. Knowing exactly what’s covered and what’s not helps you steer clear of denied claims.
2. Match the treatment to the right type of claim: Whether it’s daycare procedure, special therapy, or pre- or post-hospitalisation tests, don’t mix them up.
3. Store everything: Doctor prescriptions, hospital bills, lab reports, payment slips — treat them like gold. One missing paper can cost you your claim.
4. Be honest and accurate: One wrong date or spelling error might hold up the entire process.
5. Know your waiting periods: Some treatments aren’t covered from day one. Check how long you need to wait before raising a claim for those specific conditions.
6. Choose a hospital that’s on our list: Going to a partner hospital makes cashless claims difficult. You’ll get treated, and we’ll take care of the bills directly.

Why Choose RenewBuy for Health Insurance

Navigating paperwork, interpreting complex policy language, and enduring lengthy call queues can be challenging. Recognising this, RenewBuy has developed a streamlined approach to obtaining health insurance that prioritises clarity and understanding. The platform offers a selection of carefully curated plans, enabling users to compare options effectively. Additionally, RenewBuy provides timely reminders to ensure that policies are renewed before expiration. Should you have any inquiries, the team of financial experts is readily available to assist with tasks such as processing health insurance claims efficiently.

Conclusion

Filing a surgery claim in health insurance doesn't have to be overwhelming if you follow the right process. Whether you opt for a surgery cashless vs reimbursement, clarity, documentation, and timely submission are key. By staying informed and organised, you can ensure your claim is processed smoothly, allowing you to focus on recovery. Partnering with a reliable platform like RenewBuy can further simplify the journey, offering expert support every step of the way.

Disclaimer: The content published in this article is intended solely for the readers' informational purposes and should not be relied upon for personal, medical, legal, or financial decisions. It is advisable to seek advice from a qualified professional regarding specific concerns. The details provided regarding the plan are for reference purposes only. Please visit the insurer’s website for the latest updates on the plan. The company does not guarantee suitability, reliability, timeliness, or accuracy of the information, services, or any other aspects mentioned in this regard for any purpose. We do not endorse any insurance company or insurance product provided by any insurer.