Cashless Claims in Health Insurance

What is a Cashless Claim in Health Insurance?

Cashless claims in health insurance allow policyholders to receive medical treatment without paying the hospital bill upfront. Instead, the insurance company directly settles the bill with the hospital, covering eligible expenses as per the policy terms. Most health insurers in India typically settle these claims within 1-2 hours.

Notably, cashless claims were previously applicable only in network hospitals of insurance providers. However, with the introduction of the “Cashless Everywhere” benefit, policyholders can now receive cashless medical treatment at any hospital of their choice, even if it is not part of the insurer's network.

NOTE: To avail this benefit, the insurer must be informed at least 48 hours before hospitalisation for planned treatments and within 48 hours of hospital admission in case of emergency.

How to Initiate Cashless Claims in Health Insurance?

Initiating a cashless claim request in mediclaim insurance is hassle-free and quick. Here are the steps to follow:

Step 1: The policyholder must inform the insurance company about the hospitalisation at least 48 hours in advance in case of a planned medical procedure and within 48 hours in case of an emergency.

Step 2: Upon arrival at the hospital, the policyholder must present the health insurance card at the insurance desk and complete the pre-authorisation form provided by the hospital.

Step 3: The completed pre-authorisation form, along with the required documents, must be submitted to the hospital authorities, who will then forward them to the insurance provider for review.

Step 4: The insurer will assess the submitted documents and determine whether to approve or reject the cashless claim request.

Step 5: If the request is approved, the policyholder can proceed with the treatment. At the time of discharge, all necessary documents must be signed, and any non-covered expenses, including co-payment, if applicable, should be paid.

Step 6: The insurance provider will settle the remaining medical expenses directly with the hospital.

NOTE: If the cashless claim is denied, the policyholder must pay the hospital bill upfront and later submit a reimbursement claim request to the insurer.

Advantages of Cashless Claims in Health Insurance

Take a look at some of the key benefits of cashless claims in health insurance:

• No Need for Upfront Payments- Cashless health insurance claim allow policyholders to receive medical treatment without making any out-of-pocket payments. The insurer directly settles the hospital bills, ensuring individuals can focus on their health rather than financial concerns.
• Flexibility in Choosing Hospital- Policyholders can avail of cashless claims at any hospital across the country. This provides them the flexibility to choose a well-equipped healthcare facility without the stress of arranging immediate funds.
• Quick Medical Attention During Emergencies- In critical situations, cashless claims enable patients to receive treatment without delays, as there is no need to arrange money or complete complex financial paperwork before hospitalisation.
• Simplified Hospitalisation Process- With cashless claims, hospitals coordinate directly with the insurer to complete the required formalities. This makes the admission and treatment process hassle-free for patients and their families.
• Minimal Documentation Requirements- Cashless claims require significantly less paperwork compared to reimbursement claims. The insurance company and the hospital handle most of the documentation, making the process smoother for the policyholder.
• Stress-Free Recovery- By eliminating the financial burden of hospitalisation, cashless claims allow policyholders to recover without worrying about submitting reimbursement requests or managing medical expenses.
• Peace of Mind- Knowing that the insurer will directly cover medical expenses provides peace of mind to policyholders. They can focus on their recovery rather than worrying about managing hospital bills.

Documents Required for a Cashless Health Insurance Claim

To get a cashless claim under a health insurance policy, the insured need to provide the following documents:

• Pre-authorisation form
• Health card or policy document
• Valid ID proof and a photograph
• Personal identification documents such as PAN card, voter ID, driving license, Aadhaar card, etc.

NOTE: Policyholders do not need to submit medical bills or documents to the insurer. Instead, the hospital handling their treatment sends all required documents directly to the health insurance company.

Reasons for Cashless Claim Rejection in Health Insurance

Cashless claim rejections in health insurance can happen for various reasons that are as follows:

1. Policy Exclusions

   If the medical treatment or service is not covered under the health insurance policy, the claim may be rejected.

2. Non-Disclosure of Pre-Existing Diseases (PEDs)

   If the insured fails to disclose PEDs at the time of policy purchase, claims related to those conditions can be rejected.

3. Delayed Intimation

   Failure to inform the insurer about planned or unplanned hospitalisation within the stipulated timeframe may result in cashless health insurance claim rejection.

4. Waiting Period

   Most medical insurance policies have waiting periods for certain conditions or treatments, such as maternity or pre-existing diseases. So, if a claim is made during the waiting period, it may be rejected.

5. Insufficient Sum Insured

   If the claim amount exceeds the sum insured or the available balance, health insurance companies may refuse payment or offer a partial settlement.

6. Incomplete Information

   If the insurer finds that details in the pre-authorisation form are missing, unclear, or inconsistent, they may reject or delay the approval of the cashless claim.

7. Policy Lapse

   If the mediclaim insurance policy has expired or premiums are unpaid at the time of hospitalisation, the claim may be denied.

What to Keep in Mind While Opting for Cashless Claim in Health Insurance?

Here are a few things that one should keep in mind while choosing a cashless claim in health insurance:

• It is essential to inform the insurer within the specified timeframe to ensure smooth claim processing. Any delay in intimation may lead to claim rejection.
• Policyholders must carry necessary documents such as their health insurance policy, identification proof, medical reports, doctor's prescription, and any other paperwork required by the insurer.
• Health insurance policyholders must review the policy details beforehand to understand what expenses are covered and which exclusions apply, preventing last-minute financial surprises.
• Policyholders should be aware of co-payment and sub-limit clauses, if any, in their medical insurance policy.
• Even in a cashless claim, policyholders must keep copies of bills, discharge summaries, and medical reports to avoid potential disputes and facilitate further reimbursement, if needed.