Health insurance providers usually tie-up with certain hospitals across the country where policyholders can avail cashless treatment. These medical establishments are called cashless hospitals, network hospitals, or empanelled hospitals. Policyholders can avail cashless treatment at network hospitals for both planned and unplanned/emergency medical procedures.
If the policyholder chooses to undergo cashless treatment at a network hospital, the insurance provider will settle the individual’s medical bills directly with the hospital/healthcare provider. Thus, the policyholder will have to incur minimal out-of-pocket expenses when undergoing a treatment at a network hospital.
Procedure to Avail Cashless Treatment
The procedure to avail cashless treatment will vary from insurer to insurer. The general procedure to avail cashless treatment at a network hospital is as follows:
- If you wish to undergo a planned medical procedure, you will need to intimate the insurance provider or the designated TPA of the same a few days before the date of the procedure. For emergency hospitalisation, the policyholder or the policyholder’s family members will need to intimate the insurer/TPA of the admission within a few hours of the hospitalisation.
- Post intimating the insurer/TPA, policyholders can walk into any network hospital of their choice on the intended date of hospitalisation with the insurer-provided health card.
- The policyholder or the network hospital will then have to fill-up and send the pre-authorisation request form to the insurance provider with details about the treatment. The hospital will also send the estimated cost of the treatment to the insurer.
- The insurance provider will then verify the pre-authorisation request. If everything checks out, the cashless claim will be approved.
- During your discharge, you will only have to pay for inadmissible expenses, the deductible, etc., if applicable. The medical expenses, subject to the limits mentioned in your policy, will be settled by the insurance company directly with the hospital.
What is not Covered under Cashless Hospitalisation
A health insurance policy is meant to provide you a cover against necessary medical expenses that you may have to incur in the event of an emergency hospitalisation or if you have to undergo a planned medical treatment. Therefore, there will be certain non-medical expenses that may be billed to you that your cashless health insurance claim will not cover, such as:
- Hospital registration desk fees
- Expenses incurred on toiletries
- Service charges
- Attendant’s fees
Note: The charges mentioned above are not exhaustive. For a full list of exclusions, make sure to check the policy brochure.
Things to Keep in Mind when Opting for Cashless Hospitalisation
- Cashless hospitalisation can only be availed at network hospitals. Thus, when you purchase a health insurance policy, you will need to make a note of all the network hospitals in your city/town of residence.
- Read through the policy document carefully and familiarise yourself with the inclusions and exclusions of the policy.
- Most health insurance providers will require you to display your health card at the hospital before seeking admission. Thus, make sure to carry the health card with you at all times.
- When filling the pre-authorisation form, make sure that you fill the correct details to ensure that your pre-authorisation request does not get rejected by the insurance provider.
- In case of an emergency hospitalisation, make sure that the insurance provider/TPA is intimated of the hospitalisation before the completion of the timeline specified by them.
- Your cashless claim will only cover the medical expenses that you incur during the hospitalisation. Hence, make sure that you have enough funds to pay for your non-medical expenses and other inadmissible charges.
- Certain times, cashless claim requests may be rejected by the insurance provider due to insufficient details or other such factors. In such a case, you can still complete your treatment at the hospital, settle your bills with the healthcare provider directly, and then raise a reimbursement claim for the same.
Reasons why your Cashless Claim could be denied
Your cashless health insurance claim may be denied by the insurance provider if:
- The ailment/medical condition for which you are seeking treatment is not covered by your health insurance policy.
- The hospital you are undertaking treatment in is a non-network hospital.
- The pre-authorisation request form is filled incorrectly.
- The documents that are required by your insurance company are not provided on time, either by you or by the hospital.
- The sum insured has already been exhausted.
- The claim is made during the policy’s waiting period.
- The policy has expired.
The main advantage of opting for a cashless claim is that it can lower your out-of-pocket expenses in the event of a medical emergency or hospitalisation. However, you should make sure that you are aware of your insurer’s cashless claim process and the terms and conditions governing this in order to avoid any last-minute surprises.