Cashless Health Insurance

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A sudden illness or an unfortunate accident can not just cause mental and physical trauma, but can also lead to a big hole in the pocket. Having a health insurance plan in today’s time is imperative, especially when the pandemic is still looming over our heads. There’s an increase in the number of lifestyle diseases when inflation in the field of healthcare is steadily rising. Even minor illnesses or a few trips to a general practitioner can become a financial burden.

These concerns are on the rise and many health insurance companies are coming up with a cashless health insurance claim process.

What is Cashless Health Insurance?

Let us first understand what Cashless Health Insurance is. 

Your health insurance company has a tie-up with various hospitals or a chain of hospitals, these are called the ‘network hospitals’. When you visit a hospital listed in the network hospitals by the insurer for treatment, the bills are settled directly by your health insurance company. 

Because you are not required to pay any money, it is called Cashless Health Insurance. 

As compared to the Reimbursement way of settling the claim, in which first you pay the hospital bills and then you are reimbursed, the Cashless Health Insurance is considered to be more beneficial and a quicker process. 

Example: Last week, Mr. Vikas Mehra’s wife suffered from chronic pain in the abdomen in the middle of the night. She was rushed to the hospital and was diagnosed with uterine fibroids and had to undergo surgery. But because Mr. Mehra had a family floater Cashless Health Insurance, he did not have to pay the medical expenses from his pocket, and rather than running around raising money, he concentrated fully on his wife’s comfort and treatment. 

Given below are the main types of Cashless Health Insurance plans that are available:

  • Senior Citizen Cashless Health Insurance-
    • Health insurance for senior citizens
    • Especially crafted plans for people above 60 years of age
  • Individual Cashless Health Insurance-
    • A single member, the policyholder, is insured for a specific period
    • Cover can be claimed when the insured is hospitalised
  • Family Floater Cashless Health Insurance-
    • All family members are covered with one fixed sum insured
    • Covers policyholder, spouse, and dependent children
    • Certain policies cover parents, relatives, and in-laws too

Features of Cashless Health Insurance

A Cashless Health Insurance plan comes with a wide range of features and covers almost all aspects of healthcare. 

  • Pre & Post hospitalisation and in-patient hospitalisation expenses
  • Domiciliary treatments
  • Daycare Procedures
  • Emergency Ambulance cover 
  • Value-Added Services
  • Free Health Check-ups
  • No-Claim bonus
  • In-patient hospitalisation
  • Organ Donor Cover
  • Critical Illness Cover

Note: The total coverage of health insurance plans are mentioned above. However, only in-patient hospitalisation expenses can be paid through cashless claims. The rest of the claim, before and after hospitalisation, ambulance, free health check-ups, etc. need to be done on a reimbursement basis only.

How Does Cashless Health Insurance Work?

The importance of Cashless Health Insurance is realised when you or any other insured member of your family gets hospitalised. As most health insurance companies deal with the network hospitals directly, they may have different ways of working but the basic process remains the same. 

To see how Cashless Health Insurance works, read on.

  1. Network Hospitals: 
    In case hospitalisation is needed for you or any other insured member, you first need to check the list of all associated hospitals. Generally, most health insurance companies have tie-ups with hundreds of hospitals, you may select the one that is closest to you.
  2. Claim Intimation:
    In case the hospitalisation is planned, it is recommended that you inform the company at least 72 hours before the proposed date. However, if it is an emergency hospitalisation, you can inform the company within the first 24 hours.
  3. Health Card:
    When you buy Cashless Health Insurance, you are provided with a Policy/Health Card, which you must present to the hospital authority/insurance desk at the time of admission along with the insured’s KYC documents. 
  4. Pre-authorisation:
    Once you do that the hospital will issue you a pre-authorisation form for the initial approval from the insurance company. After the forms are duly filled, signed and submitted, the hospital will share the same with the TPA, Third-Party Administrator of the insurance company directly. 
    Note: Third Party Administrator (TPA) is like a mediator between the health insurance company and the hospital for some insurance companies. It is an organisation that works for both corporate and retail health plans and works to provides cashless-service benefits in a timely, cost-effective, and smooth manner. 
    However, the new-age health insurance companies, especially the Stand Alone Health Insurance (SAHI) companies do not have a TPA Desk. The claim is settled directly by the insurer.
  5. Other than in-patient hospitalisation: Once these formalities are over, the insurance company and the hospital will do the rest for you. All you need to do is oversee and then go ahead and claim the pre and post-hospitalisation on a reimbursement basis.

Benefits of Cashless Health Insurance

Many policyholders consider Cashless Health Insurance to be an excellent formula to deal with sky-rocketing healthcare costs. In case of a medical emergency, it surely acts as a blessing, let us take a look at the benefits of a Cashless Health Insurance Plan.

  • Huge Coverage
    Almost all health issues and in-patient hospitalisation expenses are covered under the Cashless Health Insurance Claim. The other features like pre and post hospitalisation charges, health check-ups, day-care procedures, etc are generally offered on a reimbursement basis. Some health insurance companies also offer add-ons like parental care, maternity, and newborn baby cover, recharging of the sum insured, etc. 
  • Instant Cashless Treatment
    Going to a network hospital is very convenient as you get an instant treatment facility. You need not pay any money out of your pocket even for the best of treatments and services. Most health insurance companies have tie-ups with hospitals/chains of hospitals that are spread across the country, therefore, whether you are at your residence or are travelling, you will be under the cover of your health insurance policy.
  • No Need to Wait
    With Cashless Health Insurance, whether your hospitalisation is planned or because of an emergency, you do not worry about first raising the money for the treatment and then waiting for reimbursement. The entire process is easy and problem-free.
  • Sense of Security
    Life is unpredictable, a medical crisis at home can cause a great deal of anxiety and tension. Under such a situation if the financial part of treatment is taken care of, it can act as a big load off your shoulders. You would be in a position to handle unpredictable situations with much more ease and confidence.
  • Saving Taxes
    The premium that you pay towards your Cashless Health Insurance can be claimed for tax-exemption under Section 80D of the Income Tax Act. 

Tax Deductions Under Section 80D

ScenarioPolicyholder, spouse, 2 childrenParentsTotal Deduction 
All family members under 60 yearsUp to INR 25,000Up to INR 25,000INR 50,000
Parents above 60 while the policyholder is <60 yearsUp to INR 25,000Up to INR 50,000Up to INR 75,000
Policyholder and Parents both over 60 yearsUp to INR 50,000Up to INR 50,000INR 1 lakh

Steps to File a Cashless Health Insurance Claim

The Third Party Administrator works as a mediator between the hospital and the health insurance company and plays a significant role in speeding up the claim processes. They have their associates at the hospital who help the claimants. 

A Cashless Health Insurance claim can be made in several ways, let us discuss them all in detail:

  1. Planned Hospitalisation 
    If your hospitalisation is planned, you can plan your claim in two ways- Online or Offline:
    Making a Cashless Claim Online 
    Step 1- Visit the health insurance company's official website and look out for the list of network hospitals. Select the one that is most convenient for you, in terms of facilities/ services offered and the distance from home. 
    Step 2- When you reach the hospital, present them with your Health/Policy Card issued to you by your Health Insurance Company at the time of purchase of the policy. You need to fill in a ‘Pre-Authorisation Form’. It can be downloaded online from the TPA website.
    For some insurers, the pre-authorisation form can be filled online. This is especially handy if the claim is a planned one and the approval needs to be attained ahead of time.
    Step 3- You can fill in this form carefully and keep it ready to be submitted after the hospitalisation at the helpdesk or with the TPA associates present in the hospital. 
    Step 4- A few documents are to be submitted along with the ‘Pre-Authorisation Form’, the list is given below. 
    Making a Cashless Claim Offline
    Step 1- Your policy papers contain a list of all the network hospitals, search through them and select the one that is most convenient to you, in terms of facilities/ services offered and the distance from home. 
    Step 2- When you reach the hospital present them with your Health/Policy Card issued to you by your Health Insurance Company at the time of purchase of the policy. Then you can ask the Helpdesk or the TPA associates present at the hospital, for a ‘Pre-Authorisation Form’. 
    Step 3- Fill in this form carefully. Once you sign it, submit it at the helpdesk or with the TPA associates.  
    Step 4- A few documents are to be submitted along with the ‘Pre-Authorisation Form’, the list is given under the documents required section below. 
    After you make the request for the claim, your documents and the form would be checked by the hospital and the TPA for legalities and eligibility. Once approved the paperwork will be sent to the hospital, and it would start the cashless treatment. 
  2. Emergency Hospitalisation
    In case of an emergency hospitalisation as well, the claim can be made in two ways- Online or Offline:
    Making a Cashless Claim Online
    Step 1- Visit the health insurance company's official website and look out for the network hospitals. Select the one that is most convenient for you, in terms of facilities/ services offered and the distance from home. 
    Step 2- When you reach the hospital, present them with your Health/Policy Card issued to you by your Health Insurance Company at the time of purchase of the policy.  
    Step 3- Within 24 hours of the hospitalisation, you must inform the insurance company. You may write them an email, enclosing the documents listed below. Along with these documents you also need to attach the ‘Pre-Authorisation Form’ which can be downloaded online from the TPA website.
    Making a Cashless Claim Offline
    Step 1- Your policy papers contain a list of all the network hospitals, search through them and select the one that is most convenient to you, in terms of facilities/ services offered and the distance from home. 
    Step 2- When you reach the hospital, present them with your Health/Policy Card issued to you by your Health Insurance Company at the time of purchase of the policy. 
    Step 3-  Within 24 hours of the hospitalisation, you must inform the TPA associates present at the hospital or the insurance company either through the insurance helpdesk at the hospital or telephonically. You also need to ask the Helpdesk or the TPA associates present at the hospital, for a ‘Pre-Authorisation Form’. 
    Step 4- A few documents are to be submitted along with the ‘Pre-Authorisation Form’, the list is given below. 
    After you make the request for the claim, your documents and the form would be checked by the hospital and the TPA for legalities and eligibility. Once approved the paperwork will be sent to the hospital, and it would start the cashless treatment. 
  3. Documents required while requesting a Cashless Claim
    Different companies may have different requirements of documents and certificates, however, given below is a list of documents generally asked for: 
    • Valid Photo Identification document of the Policyholder and/or insured member who has been hospitalised
    • Copy of the Health/Policy Card
    • Pre-Authorisation Form-filled and signed
    • Bills and receipts of the Treatment done
    • All kinds of Pathological and Diagnostic Test Reports
    • Doctor’s certificate that advises hospitalisation
    • Doctor’s prescription tests, medicines, and consultations
    • Ambulance Bill, if used
    • A copy of FIR/Medico-Legal Certificate in case of an accidental injury
       

Best Cashless Health Insurance in India (2020)

No two people will have the exact same health insurance needs and thus selecting a plan depends on your own personal requirements. Yet, having an idea about the companies giving great deals will always be beneficial. Given below is a list of 5 best Cashless Health Insurance in India (2020). Take a look:

Name of the Company & the PlanHighlights of the Plan
HDFC ERGO - Health Suraksha Policy
  • Pre & Post Hospitalisation, Domiciliary Hospitalisation, Organ Donor Expenses, Maternity & Baby Expenses
  • 55 cumulative bonus on each claim-free year
  • Alternate Treatments-Ayurveda & Homeopathy
  • No pre-medical tests for people under 46 years of age
Apollo Munich Health Insurance Company - Apollo Munich Optima Restore
  • Automatic Restoration of Sum Insured
  • Pre & Post Hospitalisation, Domiciliary Hospitalisation, Organ Donor Expenses
  • Over 10,000 Cashless Hospitals
  • Portability Benefit
  • 8% renewal discounts when using the Stay Active Mobile App
  • Health Check-Ups
Care Health Insurance Company - Care Policy
  • High Sum Insured
  • 100% restoration of Sum Insured
  • Affordable with extensive cover
  • Treatment abroad
  • Complimentary Health check-Ups
  • No pre-medical tests for people under 46 years of age
  • Discounts on long-term plans
Star Health Insurance Company - Star Health Family Optima
  • Domiciliary Hospitalisation, Organ Donor Expenses, Cover for New Born Baby, 405 Day-Care procedures
  • Portability Benefit
  • 100% Automatic restoration of Sum Insured
  • Health Check-ups
  • Emergency Domestic Medical Evacuation
ManipalCigna Health Insurance Company Limited - Manipal Cigna Prohealth Plan
  • High Sum Insured, Health Maintenance Benefit, Maternity & Baby Expenses
  • Options of Voluntary deductibles
  • Unlimited restoration of Sum Insured
  • Inflation Protection
  • Complimentary Health check-Ups

 

Cashless Health Insurance FAQs

  • 1. Can I file a cashless health insurance claim during the grace period?

    No, after the policy expires you are no longer eligible to make a claim. The grace period is only a 30-day window given to you to renew your policy, however, if you do not pay and renew the policy, despite the grace period, you will not be able to avail any benefits of the health insurance.

  • 2. What is the role of TPA in the cashless health insurance settlement process?

    TPA, Third-Party Administration , was introduced by IRDA in 2001. It is an organisation that works for both corporate and retail health plans and works to provide the cashless-service benefits in a timely, cost-effective and smooth manner. It plays a key role as its responsibilities are:

    • Efficient delivery of facilities
    • Standardisation of all process
    • Wipes out customer-confusion
    • Makes understanding and managing health insurance easy
    • Avoid fake claims
    • Restricts unnecessary treatments
  • 3. What are the documents required to file a cashless health insurance claim?

    Different companies may have different requirement of documents and certificates, however, given below is a list of documents generally asked for: 

    • Valid Photo Identification document of the Policyholder and/or insured member who has been hospitalised
    • Copy of the Health/Policy Card
    • Pre-Authorisation Form-filled and signed
    • Bills and receipts of the Treatment done
    • All kinds of Pathological and Diagnostic Test Reports
    • Doctor’s certificate that advises hospitalisation
    • Doctor’s prescription-tests, medicines and consultations
    • Ambulance Bill, if used
    • A copy of FIR in case of an accidental injury
  • 4. Can I claim for a cashless treatment if I am not admitted to one of the network hospitals?

    A hospital or a healthcare centre or a medical clinic that has a tie-up with a health insurance company for giving cashless treatment to the policyholders is called a network hospital. Unless you are admitted into a network hospital, you would not be able to get the cashless treatment. However, you might be eligible for reimbursement, but it is recommended that you confirm all the details from your health insurance company. 
     

  • 5. Why should I opt for Cashless Health Insurance?

    As compared to the Reimbursement way of settling the claim, in which first you pay the hospital bills and then you are reimbursed, the Cashless Health Insurance is considered to be more beneficial. Going to a network hospital is very convenient as you get an instant treatment facility. You need not to pay any money out of your pocket even for the best of treatments and services. 

  • 6. What points should I keep in mind before I buy  Cashless Health Insurance?

    Keep the following points in mind:

    • Important to have adequate coverage
    • Important to consider the claim-settlement ratio
    • Consider the Exclusions
    • Go for an insurer that has a wider network of hospitals
    • Shorter Waiting period
    • Option of Portability
    • Premium Amount should be affordable
    • Availability of Riders
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