OPD bill for health insurance reimbursement: what the clinic should give What IRDAI requires, what the policy decides, and the receipt an insurer can check.

IRDAI does not set out what an OPD bill must contain: each insurer must list the documents it needs for a claim in the policy document and on its website, so the patient's policy decides what is submitted. What a clinic controls is a receipt that an insurer can check against the prescription, showing the patient's name, the date, the doctor's name and registration number, each charge itemised, the amount and payment mode, a receipt number and a signature.

The general rules for a clinic receipt, including GST, numbering, voids and the cash limit, are in clinic bill format: what a receipt must show. This post covers only what changes when the receipt is going to an insurer.

Does IRDAI say what an OPD bill must contain?

No. We read the two IRDAI documents that govern health claims today and neither prescribes the fields of a provider's bill. What they do is put the duty on the insurer to tell the policyholder what to submit.

• The Master Circular on Protection of Policyholders' Interests, Ref. IRDAI/PP&GR/CIR/MISC/117/9/2024 dated 5 September 2024, lists the matters a health insurance policy "shall clearly state". They include the "Action to be taken on the occurrence of a claim for cashless and reimbursement options separately", the "Procedure for claims submission, timelines ... along with all the claims documents required for claim processing", and "the list of documents that are required to be submitted by a claimant in case of a claim under the policy".
• The Master Circular on Health Insurance Business, Ref. IRDAI/HLT/CIR/PRO/84/5/2024 dated 29 May 2024, requires insurers to display on their websites the "Procedures to be followed by the policyholder for claim settlement under cashless facility and reimbursement of claims". Its Customer Information Sheet format has a claims row for "Details of procedure to be followed for cashless service as well as for reimbursement of claim".

So when a patient asks what the bill should say, the honest answer is: check your policy's claim document list, or the insurer's website. The clinic's job is to make whatever the policy asks for easy to verify. We checked the IRDAI health department page on 27 October 2026; the 29 May 2024 circular is still the latest master circular on health insurance business listed there.

Is OPD covered under a normal health policy?

Only if the patient's policy or an add-on includes it. The health master circular says insurers "are required to make available products/add-ons/riders" catering to "every situation of treatment including domiciliary hospitalization, outpatient treatment (OPD), Day Care and Homecare treatment". That is a duty to offer such cover, not a promise that every policy has it. The Customer Information Sheet each policyholder receives lists "OPD / Dental/ Maternity coverage" among the benefits, so the patient can see in one page whether they have it. If a patient is unsure, point them to that sheet rather than guessing at the desk.

What should a clinic's OPD receipt show for a claim?

An insurer checking an OPD claim wants to see who was treated, by whom, when, for what, and that the money was paid. None of the fields below is set by IRDAI; the registration number is set by the NMC code, and the rest is what makes a receipt verifiable.

The free clinic receipt format tool prints a receipt with these fields, including the registration number and the amount in words.

Does the patient need the prescription as well as the bill?

Usually, but the policy's document list is what decides. A receipt shows what was paid; the prescription shows why, and its date and doctor should match the receipt. Give the patient the original prescription and the original receipt at the visit. If they come back later for copies, regulation 1.3.2 of the 2002 regulations gives you 72 hours to issue records they ask for; the details are in a patient wants their medical records.

Do not write a diagnosis on the receipt unless the patient asks for it. The prescription already carries the clinical note, and the receipt is often handed to more people.

What if the insurer or TPA calls the clinic directly?

IRDAI's policyholder circular says that after a health claim is intimated, "Insurers and Third-Party Administrators (TPAs), shall collect the required documents from the Hospitals. Policyholder shall not be required to submit the documents." A clinic may therefore get a call or email asking to confirm a visit or send papers. Regulation 7.14 of the 2002 regulations bars disclosing a patient's secrets except in listed situations, and an insurer's request is not one of them. Ask for the patient's written consent before sending anything beyond confirming that the receipt number and amount are genuine, and send only what the consent covers.

Can the clinic issue a duplicate or corrected bill for a claim?

A duplicate, yes, if it is marked as a duplicate and carries the original receipt number, date and amount. A corrected receipt only through a void and re-issue with the reason recorded, as our receipt post explains. Never change the date, the amount or the patient's name to fit a policy. A receipt is evidence of a payment that happened on a given day; writing a different one is not a clerical favour.

How long does the insurer have to settle an OPD claim?

These are the lines from IRDAI's Master Circular on Protection of Policyholders' Interests that the desk can repeat to a patient who asks:

• "Settlement of claims (other than cashless) shall be settled within fifteen days from submission of claim."
• "No claim shall be rejected or closed for want of documents or for delayed intimation of claim."
• If a claim is not settled within the specified timelines, "the claimant is entitled for interest at bank rate plus 2 percent from the date of receipt of intimation to till the date of payment", paid by the insurer on its own.
• If a claim is rejected or partly disallowed, the details are communicated "with full details giving reference to the specific terms and conditions of the policy document."
• A complaint to the insurer is acknowledged immediately and resolved "within 14 days". A complainant who is not satisfied can go to the Insurance Ombudsman, without any fee, where the claim amount is up to ₹50 lakh, and can also register a complaint on IRDAI's Bima Bharosa portal.

These are the insurer's obligations to the policyholder. The clinic is not a party to the claim and cannot guarantee that a claim will be paid; say so if a patient asks.

A desk checklist for insurance receipts

1. Ask whether the patient will claim, and take the name exactly as it appears on the policy.
2. Bill each service on its own line; never one lump sum.
3. Make sure the registration number of the treating doctor is on the receipt.
4. Record the payment mode, and the amount in words.
5. Hand over the original receipt with the original prescription, dated the same day.
6. For a duplicate later, mark it "Duplicate" and keep the original number and date.
7. Release nothing to an insurer or TPA without the patient's written consent.