The Ultimate Guide to Cashless Medical Claims in Health Insurance

Everything you need to know about making Cashless Medical Claims.

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The facility of a cashless claim in health insurance is truly one of the biggest benefits of having medical coverage. Illness often strikes when we are least prepared to deal with it.

Cashless hospitalization, at least, saves you from the hassles of arranging funds at the eleventh hour.

Now, if you have just bought your very first health insurance policy, you might have a few questions about the cashless claim process, its benefits, and limitations.

If so, you have come to the right place. This article will take you through all you need to know about making a cashless insurance claim so that you are prepared when need arises.

Let’s get started.

What is cashless hospitalization?

Cashless hospitalization means that your hospital bills get settled directly between the insurer and the treatment centre, with the help of a third-party administrator. All you need to do is intimate your insurance provider that you will be availing of cashless treatment. They will advise you on the next steps you need to take. Do bear in mind that a cashless claim will only hold if it is made at a network hospital.

Decoding the Cashless hospitalization jargon:

Let’s see what these commonly used phrases in cashless health insurance mean.

Network hospital

Every insurance provider has tie-ups with certain hospitals. These hospitals are called network hospitals. Network hospitals offer cashless treatment at rates that have been negotiated with the insurer.

The insurer benefits by paying lower costs for claims and network hospitals receive an assurance that policyholders will choose their facilities for healthcare.

Third-party administrator (TPA)

The third-party administrator (TPA) offers intermediation services between the policyholder and the insurance company during a cashless claim.

The TPA helps settle cashless claims, assists policyholders with queries, and even empanels network hospitals for the insurer.

The TPA must be licenced to operate by the Insurance Regulatory and Development Authority of India (IRDAI).

Looking at the cashless claim process

A cashless medical claim can either be made for planned hospitalization or emergency hospitalization.

Here is an overview of the steps involved for each.

Planned hospitalization

If the treatment has been planned ahead, you would need to begin the cashless claim request at least 5 days in advance. Here are the steps to follow:

Step 1: Look up the list of network hospitals in your locality and pick a medical centre that proves most convenient for you.

Step 2: Fill up the pre-authorization form. This form is available at the network hospital or online on the TPA’s website. The completed form needs to be submitted at the insurer’s desk at the chosen network hospital.

Step 3: Receive approval with details of coverage sanctioned. On the day of hospital admission, you would need to present your insurance ID card or policy number and the authorization letter for cashless treatment. You must ensure that hospital admission happens within the time-frame of the approval’s validity.

Emergency hospitalization

More often than not, hospitalization is done in an emergency. If this is the situation, here are the steps to follow for the cashless claim process.

Step 1: Complete the pre-authorization form within 24-hours of hospitalization.

Step 2: The insurance desk at the hospital sends your request across. Your approval should come through in a few hours.

Step 3: Wait for approval from the TPA. If there is no time to carry out this process during an emergency hospitalization, you may pay for the expenses on your own and apply for reimbursement later.

Do bear in mind that insurers often have a strict deadline for the cashless claim process in case of emergency hospitalization. This deadline is usually between 24 to 48 hours and varies between insurance companies.

Benefits of cashless claims

The benefits of having the facility of cashless claim in health insurance are pretty evident and yet, they deserve to be spelled out. To begin with, you are saved from the hassle of arranging for funds at the last minute during an illness.

As we all do know, the costs of medical care can run high, often into lakhs of rupees. Not too many people have that kind of cash lying around in their savings. Cashless hospitalization allows you to get the best in medical care without needing to worry about the cost.

After all, there is no price tag to getting timely treatment. This gives you, the policyholder, real peace of mind during a time when you are already grappling with ill health.

Tips to keep in mind

Making a cashless claim for the first time? Here are a few tips to keep in mind.

  • Inform at the earliest

Inform your insurer at the earliest to allow them enough room to review and authorize your claim request. This may be disregarded in case of emergency treatment.

  • Know the exclusions

Do be sure to ask your insurer for a full list of exclusions. Knowing what you pay for out-of-pocket will help you balance your expenses during hospitalization. It will also prevent any kind of confusion later on.

  • Keep insurer contact details handy

Always have your insurer’s toll-free number handy on your smartphone. In the event of an emergency hospitalisation, you can get quick assistance at any hour.

  • Provide accurate details

The pre-authorization form will need information such as the patient’s medical history, treatment advised, pre-existing conditions, and cost of services. Make sure to fill up these details accurately and honestly so that your claim gets processed smoothly.

Are there any exclusions to cashless claims?

Yes, your health insurance policy fine print will list out exclusions that cannot be covered under the policy. Generally, expenses such as medical records charges, laundry charges, telephone charges, costs incurred by visiting relatives, nebulizers, diapers, and toiletries are excluded from coverage. You will have to pay for these separately at the hospital where you are admitted.

A cashless medical claim indeed has so many advantages to offer you, the policyholder. With the cashless claim facility, you can focus on what matters the most – your health. We hope that this quick guide on cashless claims has proved helpful for you.


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