A health insurance plan provides a way for policyholders to effectively manage their healthcare expenses. If you have a health insurance policy and you undergo hospitalisation or need to avail a medical treatment, you can either raise a reimbursement claim or a cashless claim. Thus, cashless health insurance is simply a type of claim that you raise with your insurance provider, wherein the insurer will settle your admissible medical expenses with the healthcare provider/hospital directly. If you opt for a cashless claim, you are likely to have lower out-of-pocket expenses.
What do Cashless Claims Cover?
The medical expenses that will be covered when you raise a cashless claim with your insurance provider will vary based on the terms and conditions of your health insurance policy. That being said, most health insurance policies provide coverage for the following expenses:
- Inpatient hospitalisation
- Pre and post-hospitalisation
- Daycare procedures, as specified in your policy brochure
- Domiciliary treatment
- Organ donor treatment
- AYUSH (Ayurveda, Yoga, Unani, Siddha, and Homeopathy) treatments
- Hospital daily cash benefit
- Ambulance charges
*Note: The policy inclusions mentioned above are not exhaustive, and the coverage offered to a policyholder will vary from policy to policy.
Exclusions under Cashless Claims
In most cases, cashless health insurance claims cover all permissible medical expenses up to the sub-limits specified in your policy document. The cashless claim will, however, not cover non-medical expenses and any expenses that you might incur above the sum insured limit or the sub-limits of your policy. Further, a few common exclusions that are applicable to most health insurance plans are listed below:
- Illnesses/Pre-existing diseases during the due waiting periods
- Injuries caused due to war, war-like operations, invasion, nuclear weapons, etc.
- Dental treatments, costs of spectacles/lenses, cosmetic surgeries, etc.
- General debility and convalescence
- Medical expenses as a result of alcohol intoxication or drug abuse
- Congenital external diseases/defects/anomalies, venereal diseases, psychiatric disorders, psychosomatic disorders, etc.
- Injuries caused as a result of self-harm
- Hospital registration charges, telephone charges, admission charges, etc.
- Expenses incurred while undergoing weight control/weight gain treatments
Things You Should Know about Cashless Hospitalisation
Most people prefer to undergo cashless treatments at hospitals since it is relatively hassle-free. However, before you decide to avail the cashless hospitalisation facility that is offered by your insurance policy, here are a few things you need to know:
Know your Network Hospitals: If an insured individual opts to avail cashless hospitalisation, the insurance provider/designated TPA will settle the concerned person ’s medical bills directly with the hospital. However, policyholders will only be able to undergo cashless hospitalisation at empanelled hospitals that are a part of the insurer’s network. Thus, the insurance provider will not provide cashless hospitalisation facility to those who undergo treatments at non-network hospitals.
Read the Policy Terms and Conditions: While a cashless claim can cover many medical expenses, certain policies do not provide coverage to a few illnesses/medical ailments. Thus, it is necessary to familiarise yourself with the terms and conditions of your policy.
Carry your Health Card: Insurance providers will provide you a health card either with the policy document or after the policy document is issued. It is imperative that you carry your health card with you at all times since hospitals will require you to produce this upon arrival, even if it is an unplanned hospitalisation.
Intimate the Insurer of the Hospitalisation: Most insurance companies will require you to intimate them about the upcoming claim. In the case of planned hospitalisation, you will need to inform the insurance company or designated TPA a few days before the intended date of the procedure. Whereas, in the case of unplanned hospitalisation, you or your family member will need to inform the insurer of the hospitalisation within a few hours of being hospitalised.
Make Sure that the Pre-Authorisation Form is Filled Correctly: Either you or a hospital representative will need to fill a pre-authorisation form and send it to the insurer/TPA. Make sure that this form is filled correctly and that all the right details are mentioned since the insurance company can either accept or reject this request. If your pre-authorisation request is rejected, you will need to pay your bills in the hospital and then raise a reimbursement claim.
Advantages of Cashless Claims
- Undergoing cashless hospitalisation is a smart way for insured individuals to keep their out-of-pocket expenses to a minimum.
- Since cashless hospitalisation also covers emergency treatments, you can undergo treatments at reputed hospitals without worrying about having the funds to pay for the treatments. You will still, however, need to pay for any non-permissible and non-medical expenses that might be a part of your hospitalisation bill.
- Raising a cashless claim is usually a more hassle-free option for policyholders since they don’t necessarily have to hang on to the medical documents and bills. All bills and supporting documents will be sent to the insurance company by the hospital, in most cases.
- Unlike in the case of reimbursement claims, insured individuals do not need to wait for a few days for the insurance company to provide a reimbursement of the expenses that they incurred during the hospitalisation.
When Should You Opt to File a Cashless Claim?
Opting for cashless claims can be a boon for any individual who would like to avail quality medical care without worrying about having the funds to pay for the same. Thus, having the option to avail cashless treatments at any network hospital of your choice reduces the need for you to save significant amounts of money for healthcare needs. However, it is vital that you familiarise yourself with the terms and conditions of your policy in order to avoid any problems when raising a cashless claim.
Top 5 Health Insurance Plans that offer Cashless Facility to Policyholders
Almost all health insurance policies that are available in the market today allow policyholders to avail cashless treatments at hospitals that are partnered with the concerned insurance provider. Listed below are a few insurance plans that are offered by some of the leading health insurance providers in the country. Purchasing any one of these plans or any other policy that matches your needs can help you avail cashless medical treatments.
One Health Plan from Magma HDI General Insurance Company Ltd.: The One Health Plan comes in four variants and offers comprehensive health insurance coverage to policy buyers. The key features of this policy are:
Gold Plan from United India Insurance Company Ltd.: The Gold Plan provides coverage for inpatient hospitalisation expenses, day care procedures, room rent or board expenses, consultant/specialist fees, etc. The key features of this policy are mentioned below:
- Policy buyers can purchase add-ons or riders along with this policy.
- The policy is offered on an individual and floater basis. The family floater policy can cover up to 4 adults and 3 children.
- The proposer is required to be 18 years or over. The maximum age at entry for this plan is 65 years.
- Policy buyers can opt for a policy term of 1 year, 2 years, or 3 years.
National Mediclaim Policy from National Insurance: The National Mediclaim Policy provides coverage against hospitalisation expenses incurred by insured individuals. Further, the policy also covers over 140 daycare surgeries. The key features of this plan are:
- Policy buyers can avail cashless hospitalisation at over 7,000 network hospitals across the country.
- The insurer provides a family discount of up to 5% of the premium amount if this policy is purchased to cover more than one family member.
- Policyholders can avail free medical tests once in three years, provided no claims have been made during this period.
Health QuBE Plan from Raheja QBE: The Health QuBE Plan from Raheja QBE provides comprehensive coverage against medical ailments and also offers policy buyers the option to customise the policy coverage to meet their needs. The features of this policy are:
- Individuals between 18 years and 65 years can purchase this policy.
- Policy buyers can opt for a sum insured between Rs.50,000 and Rs.5 lakh.
- The policy offers lifetime renewability to policyholders.
- Policyholders can avail cashless treatments at more than 6,000 hospitals across the country.
Happy Family Floater Policy – 2015 from The Oriental Insurance Company Limited: The Happy Family Floater Policy – 2015 is offered in three variants – Silver, Gold, and Diamond. A few important features of this plan are:
- This policy can be purchased by any individual from 18 years to 65 years of age. Children over 90 days can be enrolled under this policy.
- The policy is offered in four variants.
- Policy buyers can purchase this policy for a duration of 1 year or 2 years.
- This policy can be renewed for the policyholder’s entire lifetime.
- When purchasing this policy, policy buyers can opt for a sum insured ranging between Rs.2 lakh and Rs.5 lakh.
- Policy buyers can opt for an optional personal accident cover along with this policy.
- This is an annually renewable policy.
- Pre-existing diseases will be covered under this policy after 4 consecutive policy years.
*Note: The above-mentioned insurance firms also offer a number of other health insurance plans. There are also several other health insurance providers that offer comprehensive health insurance solutions with attractive benefits. Policy buyers can avail cashless treatments upon purchasing any health insurance plan unless otherwise mentioned in the policy brochure.
How to Purchase Cashless Health Insurance
Policy buyers who wish to avail cashless treatments at network hospitals can purchase comprehensive health insurance plans for themselves through either online or offline channels. One can also choose to purchase health insurance policies from trusted third-party insurance websites. However, before you purchase any insurance plan, it is necessary to do a comparison of the features and prices of a few different medical insurance policies to ensure that you are making the right choice.