Getting cataract pre-authorisations approved faster

Many eye hospitals will know this scene. The surgery went well. The patient is dressed, the eye shield is on, the family has called for the car. And everyone is sitting in the corridor because the insurance approval has not come through.

The cataract operation itself is short. The paperwork around it can take most of a day. In a 2024 Pristyn Care survey reported by The Week, 38 percent of insured patients said their discharge took more than eight hours. In a 2025 LocalCircles survey, six in ten said they had waited somewhere between six and 48 hours.

The rules now set clear time limits for insurers. What follows is how cashless pre-authorisation works, what a cataract file needs, and where most delays really come from.

The rules are now on the hospital's side

In May 2024 the insurance regulator, IRDAI, issued a master circular on health insurance. Two lines in it matter to every TPA desk:

• The insurer must decide a cashless authorisation request "immediately but not more than one hour" after receiving it.
• The final authorisation at discharge must come within three hours of the hospital's request. If it takes longer, the extra cost falls on the insurer, and in no case should the patient be made to wait to leave.

The same circular says insurers and TPAs should collect documents from the hospital, not make the patient run around for them, and that pre-authorisation should be available digitally.

Insurers say they are largely meeting this. Figures given in Parliament in December 2025, as reported in the press, put 87 percent of pre-authorisations decided within one hour and 97 percent of discharge approvals within three hours. So when a patient is still waiting at four in the afternoon, it helps to check whether the file was complete when the clock started.

Why "one hour" often is not one hour

Practitioners say the one-hour clock works on a complete request, and the circular does not say whether it restarts after a query. A file with a missing document is usually not refused. It gets a query, and the patient waits while someone finds the paper and sends it again. People in the industry say the same thing in different words. As one adviser told Mint in May 2026, "A lot of claims get rejected simply because the first consultation document is missing."

An insurer's claims head said in the same article that pre-auth approvals are conditional. If the diagnosis changes or information turns up missing at discharge, an approval given in the morning can be cut in the evening.

So quick pre-authorisations are not the ones with the most follow-up calls. They are the ones that go out complete the first time.

What a cataract pre-auth file needs

Every insurer and TPA has its own form, and published TPA guidance for cataract most often mentions these items. A file that goes out with them in hand usually moves faster:

• The signed pre-authorisation form, with the patient's photo ID and the policy or TPA card
• The consultation note that advises surgery, with the diagnosis, the eye (right or left) and the visual acuity
• The A-scan or biometry report
• The planned lens: manufacturer, model, power and its cost, with the IOL sticker or invoice where asked
• The cost estimate, with the lens cost shown separately

Medi Assist, a large TPA, has a short note on cataract claims that names three documents not to forget: the consultation note, the A-scan and the IOL details. They are named because they are easy to miss.

Know the policy before the patient is on the table

Two policy details cause more unhappy discharges than any delay.

The waiting period. Many Indian health policies do not cover cataract in the first years of the policy; some Star Health plans, for example, wait 24 months. A patient who bought a policy last year may not be covered at all, and it is far kinder to find that out in the OPD than at discharge.

The cataract limit. Many policies cap what they pay for cataract per eye: in two Star Health plans, for example, the cap runs from Rs 20,000 to Rs 50,000 depending on the sum insured. Check too whether the policy pays for a premium lens in full or only up to the cost of a standard one. If the patient has chosen a premium lens, tell them the likely difference before surgery, in writing. A patient who knows the gap in advance pays it. A patient who discovers it at the counter remembers your hospital for the wrong reason.

If you treat PM-JAY patients

Ayushman Bharat PM-JAY runs on its own portal. A panel doctor approves, rejects or raises a query on each request. Under the National Health Authority's claims FAQs, packages that need pre-authorisation are approved automatically if no panel doctor acts within six working hours, and every mandatory document must be uploaded. Check the current rule for cataract on your portal. When a query comes, the suggested time for the hospital to respond is 24 hours. The same lesson applies: upload everything the first time.

A short routine for the TPA desk

1. Check the policy, the waiting period and the cataract limit at the OPD stage, not on surgery day.
2. Collect the consultation note, A-scan and lens details as soon as surgery is advised.
3. Send the pre-auth complete, once, two to three days before surgery where you can.
4. Note the time each request goes out and the time each reply comes back.
5. Start the discharge request as soon as the surgeon signs off, not when the family asks.
6. If a reply is late, use the IRDAI timelines politely but firmly. They exist for exactly this.

The note of times in step four does more than it seems. Over a few weeks it shows you which insurer, which TPA and which document is costing your patients their afternoons.

Please note: policy terms differ between insurers and change over time. The figures here are typical examples from published sources, not the terms of any particular policy. Always check the patient's own policy.

Sources

• IRDAI, Master Circular on Health Insurance Business, IRDAI/HLT/CIR/PRO/84/5/2024, 29 May 2024, Chapter I paragraphs 15 to 17. IRDAI
• Mint, "Cashless health claim approved at admission, rejected at discharge?", 26 May 2026. Clipping
• Angel One, report on cashless approval timelines citing a Lok Sabha reply of 1 December 2025, 3 December 2025. Article
• Medi Assist, "Cataract claims: do not forget these documents". Article
• National Health Authority, PM-JAY claims adjudication FAQs, hosted by the Uttarakhand State Health Agency. PDF