Network Hospital Management — Empanelment & De-empanelment
A network hospital has an agreement with an insurer to treat policyholders on a cashless basis at agreed rates. This lesson covers empanelment and de-empanelment, who agrees the tariff, cashless versus reimbursement, and the one-hour and three-hour timelines.
What a network is
A network hospital is one that has an agreement with an insurer, directly or through its TPA, to treat policyholders on a cashless basis at agreed rates. Cashless means the insurer settles the admissible part of the bill with the hospital, so the patient does not have to pay that part first and claim it back.
Empanelment is the step that brings a hospital into the network. De-empanelment removes it. The list is therefore not fixed: a hospital in the network at the time of purchase may not be in it later, and the insurer's current list is the reference.
Standards and tariffs
IRDAI's 2024 Master Circular names no particular accreditation that a hospital has to hold for empanelment. Each insurer sets its own standards for the hospitals it takes on.
The tariff for cashless treatment is fixed by agreement between the insurer and the hospital, directly or through the TPA. The policyholder is not a party to that agreement, so a dispute over the agreed rates lies between those two. The policyholder still bears whatever the policy itself does not cover, such as a co-payment or an amount above a sub-limit, as set by the policy wording.
Cashless and reimbursement
Cashless treatment is normally available at the insurer's network hospitals. Treatment outside the network is normally claimed by reimbursement: the insured pays the hospital first and then claims from the insurer. A reimbursement claim has to be settled within 15 days of submission under the current framework.
On a cashless claim two clocks run. The insurer has to decide on the initial cashless request within one hour. When the hospital sends the discharge request, final authorisation has to be given within three hours. If it takes longer, the insurer bears any extra amount the hospital charges for the delay.
Rules at a glance
Illustration: the discharge clock
Sunita is ready for discharge from a network hospital at 10 in the morning, and the hospital sends the final bill to her insurer for authorisation then. Three hours from the request is 1 in the afternoon.
If the authorisation arrives at noon, the timeline is met. If it arrives at 4 in the afternoon and the hospital charges for the extra hours in the room, that extra amount is the insurer's to bear, not Sunita's. Her own share remains what the policy leaves to her, for instance a co-payment where the policy has one.
Key points
- A network hospital has an agreement with the insurer, directly or through its TPA, for cashless treatment at agreed rates.
- Empanelment adds a hospital to the network; de-empanelment removes it.
- The 2024 Master Circular names no particular accreditation for empanelment; each insurer sets its own standards.
- The tariff is agreed between the insurer and the hospital, not with the policyholder.
- Treatment outside the network is normally claimed by reimbursement.
- Cashless request decided within one hour; final discharge authorisation within three hours, with the insurer bearing extra hospital charges for delay.
Common misunderstandings
- Cashless does not mean the patient pays nothing: amounts the policy does not cover, such as a co-payment or the excess over a sub-limit, remain with the policyholder.
- The one-hour limit is not for discharge: one hour is for the initial request, three hours for final authorisation.
- A hospital outside the network is not outside the cover: treatment there is normally claimed by reimbursement.
- IRDAI does not prescribe a particular accreditation for network hospitals in the 2024 circular: insurers apply their own standards.
- The policyholder does not negotiate the tariff: it is settled between insurer and hospital.
Questions people ask
Who pays if discharge authorisation is late?
If final authorisation takes more than three hours, the insurer bears any extra amount the hospital charges for the delay.
Can a hospital leave the network?
Yes. De-empanelment removes a hospital from the network, so the insurer's current list is the reference.
Is the agreement always directly between insurer and hospital?
It may be direct or through the insurer's TPA.
What this lesson relies on
- IRDAI Master Circular on Health Insurance Business (29 May 2024) — cashless claims
- IRDAI Master Circular on Protection of Policyholders' Interests (5 September 2024) — claim settlement timelines
This lesson was reviewed independently against these sources on 8 October 2026. Rules change: check the current regulation, scheme document or policy wording before relying on any figure. This is education, not advice.