Health Insurance

Steps to Make Cashless Claims on Your Health Insurance?

Dec 01, 2021

While settling for any particular health insurance policy, all the aspects of claim settlement must be clarified in detail to avoid any sort of misunderstanding at the time of claim settlement. There are 2 methods of claim settlement—the reimbursement process and the cashless claim settlement process. 

Under the former method,i.e. the reimbursement process, the policyholder needs to pay the costs out of his/her own pocket during the treatment process. Later it is reimbursed by the insurance company after the amount is claimed for, supported by all the valid documents. If there is any delay or mistake in the relevant paperwork, the claim might get rejected altogether.

Cashless Health Insurance

Every insurance company maintains a list of network hospitals across the country where cashless treatment benefits are provided. If treatment is done under any of those listed network hospitals, a cashless health insurance policy benefit can be availed. This means that the bills will be directly paid by the insurance company to the concerned hospital. 

Steps to avail cashless claim

  1. In case of any medical issue, the policy benefit receiver must get admitted to any one of the network hospitals listed under the insurance company.
  2. Every network hospital maintains a special insurance desk which deals exclusively with the claim settlement issues. Either obtain a pre-authorisation form from the desk or download the same from any authorised Third Party Administrator or TPA website. TPA is an entity licensed by the IRDA and appointed by the insurance company to work on claim settlements.
  3. The filled-in form must be submitted to the insurance desk. The relevant TPA will do the necessary to process the form, sending the confirmation over email along with a sanctioned letter showing the maximum amount of treatment to be payable by the company. The insured’s KYC documents and the policy bonds/health card needs to be submitted at the time of admission along with pre-authorisation claim form.
  4. Once the basic admission procedure is over, the hospital would take care of the rest of the claim proceedings and as the policyholder, you can only liaise with the insurance company and the TPA desk of the hospital to expedite the same.
  5. At the time of discharge, the final approval of the bill would be given by the hospital. The balance amount needs to be paid by you in case a part of the claim is not payable.

Cashless claim benefits

  1. During any unprecedented medical emergency, the cashless insurance facility comes really handy, especially when a huge sum of money is involved.
  2. There is practically zero paperwork involved with cashless claim settlement. The entire process remains hassle-free and smooth.
  3. In case of a cashless settlement, the insurance companies directly pay the necessary amount to the listed network hospitals immediately. There is no need to wait for reimbursement. It saves a lot of time and concern.
  4. Cashless claim settlement becomes a blessing at the time of critical medical emergencies. The patient just needs to get admitted to any of the network hospitals without worrying about finances.

Issues for rejection of cashless claims

  1. Lack of proper information about the ailment might lead to the admissibility of the cashless claim dicey. If the insurer receives the pre-authorisation letter too late, leaving no time to verify the facts, it may lead to the rejection of the cashless claim.
    Tip: Inform the TPA/insurance company within the first 24 hours so that there is no payment issue later.
     
  2. If the policyholder is treated in any hospital, other than the ones mentioned in the list of the network hospitals followed by the insurance company, the company rightfully denies the cashless claim settlement.
    Tip: Check the list of network hospitals on the official website so that cashless claims can be availed.
     
  3. If there is no proper treatment done and there is only diagnosis or investigation, then the health insurance claim might be rejected.

Factors to consider during a cashless claim

  1. Sub-limits
    Lots of insurance plans come with the clause of sub-limits in case of certain specific ailments. The entire cost will not be covered by the company in case of the treatment of those illnesses. Such ambiguities must be clarified while buying the plan to avoid any future misunderstandings at the time of settlement.
     
  2. Self fill-up of form 
    The insurance claim form must be filled up either by the policyholder or any immediate family member. If any third party gets involved in this and makes any serious mistake, it will jeopardize the entire claim settlement procedure.
     
  3.  Complete information
    Providing all the necessary information in inaccurate detail is the primary key to claim cashless benefit. Divulge all the relevant information without keeping any secret. If any information provided is verified to be wrong, it may lead to rejection of the claim under the suppression of fact issue.
     
  4. Exclusions
    No single health insurance of the country provides and settles claims for every sort of ailment. The policyholder must have the relevant knowledge regarding which ailments are to be covered and which are excluded. All the clauses of the policy must be verified and clarified before settling.

Summary

The cashless claim facility is considered to be much wiser and hassle-free than the conventional reimbursement procedure. Here, there is no need to arrange for a huge amount of money at the critical juncture of treatment and wait for reimbursement later.

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