An approval is a payable, not a promise. Here is the escalation ladder that actually releases a cashless claim an insurer has already approved — and the exact wording that works at each rung.
This is the most common file that reaches our desk, and the most winnable. The insurer or the TPA issued an approval. The patient was discharged on it. And then nothing arrived.Hospitals often treat this as a payment delay and keep re-sending the bill. It is not a payment delay. An approval creates a payable, and a payable that is not honoured has a specific escalation path.First, work out which of the four it isBefore you write to anyone, establish which situation you are in, because the remedy differs:Approved, never credited. The approval stands and no payment has been made. This is the simplest case and usually the fastest to release.Approved, then reduced at settlement. The insurer paid less than the approved amount, typically citing a tariff, a package rate or a non-payable list applied after the fact.Approved, then reversed. The approval was withdrawn after discharge, generally after an investigation the hospital was never told about.Approved, paid to the wrong party. Rarer, but it happens — the amount was credited against a different claim or a different hospital code.Pull the approval letter, the final bill, the discharge summary and your bank statement for the period before you do anything else. If you cannot show a nil credit for the claim number, the insurer will simply reply that payment was made.The escalation ladderRung 1 — the TPA claims desk, in writingEmail, not a phone call. Quote the CCN or claim number in the subject line. Attach the approval letter and the final bill. Ask one specific question: on what date was the approved amount of Rs X remitted, and against which UTR. A request for a UTR is much harder to deflect than a request for payment, because either it exists or it does not.Give it seven working days. Keep the thread — do not start a new email each time, because the age of the thread is itself evidence later.Rung 2 — the insurer, not the TPAThe TPA administers, the insurer pays. Once the TPA has had its seven days, write to the insurer's health claims department directly and copy the TPA. The tone changes here: you are no longer asking about a remittance, you are recording a non-payment against an approval.Rung 3 — the Grievance Redressal OfficerEvery insurer in India must publish a Grievance Redressal Officer and must respond within 15 days. This is where most of our files resolve, and the reason is simple: a GRO complaint is logged, tracked and reported, and an unresolved one is visible to the insurer's own compliance team.Write it as a grievance, not a reminder. State the approval, the amount, the elapsed days, and that you have exhausted the claims desk and the insurer's claims department. Attach the full email trail.Rung 4 — the Insurance Ombudsman, or IRDAIIf 30 days pass from the grievance with no resolution, the Bima Bharosa portal and the Insurance Ombudsman are both open. The Ombudsman route has a monetary ceiling and its own procedure, and this is the point where most hospitals stop because they do not have anyone who does this regularly.What makes the differenceThree things, in our experience:The paper trail is continuous. One thread, dated, with every reply in it. A file that jumps between phone calls and fresh emails loses at rung 3.You ask for something specific. "Please release payment" invites a form reply. "Please confirm the UTR and date of remittance for CCN 123456, approved at Rs 2,45,000 on 14 August" does not.Somebody follows it every week. Most claims that die, die because nobody sent the next email. That is the whole job, and it is why hospitals outsource it.How long it should takeA clean approved-but-unpaid file resolves in four to eight weeks if it is worked properly from rung 1. Files that have been sitting for a year still resolve, but they start at rung 3 and they need the trail reconstructed first.If this is sitting in your receivables and nobody has time to run it, upload the claim to our recovery desk. We tell you within two hours whether it is recoverable, and we are paid only if the money actually arrives.