From 24-hour hospitalization intimation to gathering itemized discharge summaries, lab reports, and appealing unfair insurer repudiations.
An insurance claim is the formal contractual request submitted by a policyholder to their insurance company demanding compensation for a covered medical hospitalization, critical illness diagnosis, property damage, or death. In Nepal, claim settlement is governed by strict regulatory timelines set by the Nepal Insurance Authority (NIA / नेपाल बिमा प्राधिकरण).
Paying insurance premiums for years is pointless if your claim is rejected during a medical emergency because you lost an original pharmacy bill or reported the admission 4 days too late. Understanding the exact evidentiary checklist ensures your claim is settled smoothly within the statutory 21-to-35-day regulatory settlement window.
As soon as the patient is admitted to the hospital, email the insurance company or call their toll-free claims desk. State the patient's name, policy number, hospital name, and tentative diagnosis.
Collect: (1) Complete Discharge Summary (Chhutti Purji) detailing admission/discharge dates and treatment history, (2) Original itemized hospital bills with cash counter stamps, (3) Doctor's written prescriptions for all medicines, (4) All diagnostic reports (Blood, X-Ray, CT/MRI).
Fill out the official Claim Form. Attach your PAN, citizenship, and bank cheque photo for direct connectIPS settlement. Submit the complete physical packet to the insurer's branch and secure a stamped acknowledgment receipt.
The surveyor/medical officer assesses the claim. Upon approval, funds are wired to your bank. If the insurer unjustly repudiates the claim, submit a formal petition to the Complaints Department at Nepal Insurance Authority (Kupandole, Lalitpur).
| Required Document | Issuing Authority | Key Verification Checkpoint | Consequence If Missing |
|---|---|---|---|
| Discharge Summary | Hospital Medical Records Dept | Doctor signature, diagnosis, admission/discharge timestamps | Immediate claim rejection |
| Itemized Final Hospital Bill | Hospital Billing Counter | Breakdown of room, nursing, OT, surgery charges with official stamp | Claim halted until provided |
| Original Pharmacy Cash Memos | Hospital / Chemist Pharmacy | Matches exact doctor prescription dates and dosages | Pharmacy expenses deducted |
| Diagnostic Lab & Radiology Reports | Hospital Pathology / Imaging Lab | Signed by Pathologist/Radiologist with patient hospital ID | Investigation costs disallowed |
| Doctor's Consultation Prescriptions | Treating Medical Consultant | Doctor's NMC registration number clearly stamped | Consultation fees rejected |
Under Nepal Insurance Authority Directives, once a policyholder submits all complete required documents, the insurer is legally mandated to settle or formally repudiate the claim within 35 days. If the company delays settlement beyond this window without valid regulatory cause, they are liable to pay statutory interest on the delayed claim amount.
Laxmi underwent an emergency laparoscopic gallbladder surgery costing NPR 1,60,000. She threw away her daily pharmacy receipts, submitting only the hospital's single-page summary invoice to her insurer, which promptly rejected her claim.
Her insurance advisor guided her back to the hospital: the billing department reprinted duplicate itemized pharmacy bills and diagnostic reports with official hospital seals. She resubmitted the complete dossier with an explanation letter. The insurer approved NPR 1,48,000 (after deducting NPR 12,000 in non-medical PPE and admission charges) and transferred the cash via connectIPS within 18 days.
Goal & Dilemma: Claiming an NPR 20,00,000 life insurance sum assured following her husband's accidental death.
Total invoice presented by the treating hospital in Nepalese Rupees.
Admission charges, PPE kits, sanitizers, thermometer, deluxe food.
Agreed policy deductible percentage (typically 10% to 15% on senior policies).
Deductions applied if the selected room exceeded policy bed ceilings.
Total bill = NPR 2,00,000. Non-medical exclusions = NPR 15,000. Eligible expenses = NPR 1,85,000. Policy has a 10% co-payment clause: Co-payment = 1,85,000 * 0.10 = NPR 18,500. Net insurance payout wired to bank = 1,85,000 - 18,500 = NPR 1,66,500.
Throwing away individual pharmacy cash slips and submitting only a summary bill.
Preserve every single individual medicine receipt with its corresponding doctor prescription.
Waiting 2 months after discharge before notifying the insurance company.
Intimate the company within 48 hours of admission and submit files within 15-30 days.
Accepting claim rejection verbally over the phone without a formal letter.
Demand an official written claim repudiation letter citing the exact policy clause.
Cashless facility is available only if your insurer has a formal Third-Party Administrator (TPA) tie-up with that specific hospital. Otherwise, you pay cash and file for reimbursement.
Submit a formal written complaint with your policy copy and rejection letter to the Complaints Handling Division at Nepal Insurance Authority (Beema Pradhikaran), Kupandole, Lalitpur.
Under official Beema Pradhikaran guidelines, insurers must settle complete claims within 21 to 35 days of receiving all verified documents.
Under Nepal Insurance Authority directives, an insurance company must settle or reject a claim with written justification within 35 days of receiving all necessary documents from the claimant.
You can file a formal complaint with the Grievance Handling Cell of the Nepal Insurance Authority (नेपाल बिमा प्राधिकरण, Kupondole, Lalitpur), which possesses statutory judicial powers to adjudicate claims.