Food License Fees in India: A Complete List, Steps, and More
06 Dec, 2025
By Online Legal India
Published On 27 May 2021
Updated On 30 Oct 2025
Category ODR
Cashless hospitalisation allows insured patients to receive treatment without upfront payment, with insurers settling bills directly. But when hospitals deny this benefit, it causes emotional stress and unexpected financial strain. To safeguard policyholders, IRDAI has established a formal grievance redressal process to address issues like TPA (Third Party Administrator) lapses or insurer non-compliance. Understanding this system empowers you to take timely action and claim your rightful coverage. In this article, you will learn how to file a complaint against hospitals denying cashless treatment.
Cashless treatment in hospitals is a facility provided under health insurance policies where the policyholder does not need to pay hospital bills upfront. Instead, the insurance company directly settles the medical expenses with the hospital, as per the policy terms. This facility is available only at network hospitals—those that have a tie-up with the insurer or Third Party Administrator (TPA).
A grievance against the denial of cashless treatment can be filed by the persons listed below:
Patient (Policyholder)
The policyholder is the person whose name appears on the health insurance policy. This person pays the premium and holds the right to claim benefits. If the hospital denies cashless treatment, the policyholder can file a grievance directly with the insurer or relevant authority.
Legal Heir or Nominee
If the policyholder is deceased or unable to act due to a medical condition, the legal heir or nominee can file a grievance. The legal heir must provide documents such as a death certificate and proof of relationship. A nominee must show nomination proof as listed in the policy.
Caretaker or Family Member
In urgent situations, a close family member or caretaker can file a grievance. This applies when the patient is admitted and cannot act. The person filing must submit identity proof and treatment details to show a valid connection with the insured.
The situations when you can file a grievance against cashless hospital payment are as follows:
Cashless Treatment Denied at Network Hospital
When a hospital listed in the insurer’s approved network refuses to provide cashless treatment, it directly violates the policy agreement. This not only disrupts the treatment process but also denies the insured person access to the benefits promised under the insurance plan.
Delay in Pre-Authorisation Clearance
If the insurer or TPA fails to issue pre-authorization approval within the expected timeline, the treatment gets delayed. This can compromise the patient’s health and force the family to make urgent financial arrangements for medical care.
Hospital Claims Not Forwarded to Insurer
In some cases, the hospital does not send the necessary documents or claim forms to the insurer. As a result, the insurer cannot process the cashless claim, and the policyholder ends up paying the full treatment cost out of pocket.
TPA Miscommunication
When the TPA shares incorrect or confusing information with either the hospital or the policyholder, it causes misunderstandings. This often leads to the rejection of cashless claims or unnecessary delays in receiving treatment.
Unfair Demands for Advance Deposits
If the hospital demands an advance payment from the patient despite eligibility for cashless treatment, it defeats the purpose of health insurance. Such demands go against IRDAI guidelines and justify the need for filing a formal grievance.
Listed below are the steps to help you learn how to file a grievance against hospitals denying cashless treatment:
Step 1: Request a Written Explanation from the Hospital
If the hospital denies cashless treatment without consulting the insurer or after receiving claim approval, you must ask for a written explanation. This explanation must appear on the hospital’s official letterhead or be sent from an authorised email address. A written reason confirms accountability and supports further complaint steps.
Step 2: Submit a Complaint to the Hospital’s Grievance Cell
Prepare a formal written complaint addressed to the hospital administration. Clearly explain the issue and attach all supporting documents, such as the policy copy, admission details, and any communication showing insurer approval. Request a written acknowledgement from the hospital’s grievance cell to confirm receipt of your complaint.
Step 3: Escalate the Matter to the District Health Authority
If the hospital fails to respond or refuses to address the complaint, escalate the matter to the District Health Officer or the State Health Authority. Under the Clinical Establishments Act and other state-level health laws, hospitals must follow ethical and service-based obligations. Denial of rightful treatment violates these regulations.
Step 4: Report the Case to the State Medical Council
If the denial involves unethical conduct or refusal of essential medical care, you can report the incident to the State Medical Council. Submit a detailed explanation of the incident, attach all relevant documents, and include a copy of the complaint sent to the hospital. The Council holds the authority to examine and act on such cases.
Step 5: File a consumer Complaint
If your complaint does not get addressed in the right manner after following the above steps, you can file a consumer complaint. Consumers can file complaints either offline or through the e-Jagriti portal. The Consumer Protection Act of 2019, sets up a three-tier redressal system. They are as follows:
District Consumer Disputes Redressal Forum (DCDRF): The District Consumer Disputes Redressal Forum (DCDRF) functions at the district level and handles consumer complaints where the claim amount does not exceed 1 crore.
State Consumer Disputes Redressal Forum (SCDRF): The State Consumer Disputes Redressal Forum (SCDRF) operates at the state level. It addresses cases where the claim amount ranges from 1 crore to 10 crore.
National Consumer Disputes Redressal Forum (NCDRF): The National Consumer Disputes Redressal Forum (NCDRF) has jurisdiction over high-value complaints involving claims exceeding 10 crore.
Step 6: Documents Required to File a Consumer Complaint
To support your case effectively in the consumer complaint forum, you must gather and submit the following documents:
Health Insurance Policy Copy
A clear copy of your active health insurance policy, showing your name, policy number, and terms of cashless coverage.
Hospital Admission or Registration Slip
The document issued at the time of admission confirms your treatment request and hospital registration details.
Pre-Authorisation Request and Status (if initiated)
A copy of the pre-authorisation form submitted to the TPA or insurer, along with its approval or rejection status.
Written Denial from the Hospital
An official letter or email from the hospital stating the reason for the denial of cashless treatment. This must be issued on hospital letterhead or sent from an authorised hospital email address.
Medical Records and Doctor’s Notes
Copies of medical prescriptions, treatment plans, test reports, or discharge summaries that show the nature and urgency of the treatment.
Hospital Bills or Payment Receipts
If you were forced to pay upfront, attach all bills and payment receipts to show the financial burden caused by to denial of cashless treatment.
Communication Records
Any emails, messages, or written notes exchanged with the hospital, TPA, or insurer that help show negligence or miscommunication.
Proof of Identity
A government-issued photo ID (like Aadhaar, PAN, or voter ID) to verify your identity during the ODR proceedings.
Here are some key reasons why the Consumer Forum (now called Consumer Commissions) may not always be the best first option for resolving consumer disputes:
1. Time-Consuming Process
Legal proceedings in consumer forums can take months or even years to conclude, especially if appeals are involved.
2. Filing Costs & Documentation
Though relatively affordable, formal complaints require filing fees, notarized affidavits, and detailed documentation, which can be burdensome for small claims.
3. Legal Formalities
Even though designed for consumers, the process often involves legal jargon, formal procedures, and may require legal assistance or representation.
4. Burden of Proof on Consumer
The consumer must present solid, legally admissible evidence to support their case, which isn't always easy to gather.
5. Delays in Hearings
Frequent adjournments and overloaded case dockets can delay hearings and verdicts significantly.
What is Online Dispute Resolution?
Online Dispute Resolution is an entirely digital system for resolving disputes, utilising technology-driven platforms to facilitate every stage from the initial filing and evidence submission to virtual hearings, negotiations, and final decisions. It incorporates traditional dispute resolution methods such as negotiation, mediation, and arbitration, all conducted online via tools like video conferencing, chat, and secure document sharing. This comprehensive online workflow enables parties to engage in dispute resolution without needing to meet in person, making the process more convenient and accessible while maintaining the structured framework of Alternative Dispute Resolution methods.
Why Choose Online Dispute Resolution?
Consumers prefer ODR for several reasons:
Cost-effective & Time-efficient
Online Dispute Resolution (ODR) significantly cuts down on expenses related to travel, legal representation, and court fees. Since the entire process takes place digitally, parties can save both time and money that would otherwise be spent attending physical hearings or waiting through lengthy legal procedures. Most disputes are resolved in a matter of days or weeks instead of the months—or even years—it often takes in traditional courts.
Accessible & Convenient
ODR platforms are designed to be user-friendly and available around the clock, allowing participants to engage in the process from anywhere in the world. This makes it especially beneficial for cross-border or interstate disputes where physical presence can be challenging. Whether you’re a consumer or a business, you can submit evidence, communicate with the other party, and attend virtual hearings—all from the comfort of your home or office.
Privacy & Security
Unlike traditional court proceedings that are often public, ODR ensures a higher degree of confidentiality. Sensitive documents, communications, and decisions are securely handled through encrypted digital platforms. This protects the privacy of both parties and provides a safe, confidential environment for resolving disputes without public exposure.
How to File a Complaint through ODR?
Filing a complaint through Online Dispute Resolution (ODR) is a convenient and structured way to resolve disputes without going to court. The process is entirely digital from submitting your complaint to reaching a settlement and involves mediation and arbitration facilitated by a neutral third party.
Here’s a step-by-step guide to filing a complaint through ODR:
Step 1: Collect All Relevant Evidence
Before initiating your complaint, gather all documents and proofs that support your claim. These may include:
Having clear and well-organized evidence strengthens your case and helps the mediator or arbitrator assess your claim quickly.
Step 2: Submit Your Dispute Through an ODR Platform
Once you have all the evidence, visit an official Government ODR Portal or a private ODR platform such as Online Legal India.
Here’s what to do:
After submission, the platform will appoint a neutral mediator. The appointed professional will send a notice of mediation to the other party.
Step 3: Participate in Mediation Proceedings
In most cases, ODR begins with mediation a voluntary and non-binding process aimed at mutual settlement.
During the mediation:
After the mediation process:
Possible mediation outcomes may include:
Step 4: Arbitration
If there is any existing arbitration clause in the contract regarding a residential society, then the case will be handled through an arbitrator. During the arbitration process, a neutral arbitrator (or a panel of arbitrators) reviews the dispute and hears both sides through virtual hearings. Then, they issue a binding decision, which is known as an arbitral award. This final decision is regulated under the Arbitration and Conciliation Act, 1996. Both parties must agree and follow the final decision. If any party refuses to follow the arbitral award, the other party can approach the appropriate court. The court can then enforce the decision under the Arbitration and Conciliation Act, 1996.
Conclusion
To sum up, denial of cashless hospital treatment disrupts not only medical care but also causes avoidable financial distress. While traditional complaint routes exist, they often fall short due to procedural delays and complex litigation. Online Dispute Resolution (ODR) offers a more structured, time-bound, and valid solution to settle such disputes with hospitals. If you require any assistance in filling a complaint through ODR, get in touch with Online Legal India.
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