How Does Cashless Mediclaim Work?

How Does Cashless Mediclaim Insurance Work?

Cashless health insurance works in a streamlined process that involves the policyholder, the hospital and the insurance company. Here is how cashless mediclaim works:

1. Policy Purchase

   You need to buy a health insurance policy that offers cashless mediclaim benefits. Fortunately, all health insurance companies in India provides cashless mediclaim insurance to its customers.

2. Hospital Admission

   You must get admitted to a hospital where cashless mediclaim facilities can be availed. Earlier, cashless hospitalization could be availed at a network hospital of the insurance company. But with the introduction of the cashless everywhere facility, you can obtain cashless treatment at any hospital of your choice, even if it is not listed under the insurer's network of hospitals.

3. Notifying the Insurer

   To obtain the benefits of cashless mediclaim insurance, you need to inform the insurer about your planned or emergency hospitalization within the stipulated time. If you are aware that you will be getting hospitalized for medical treatment, then you must inform the insurer at least 48 hours in advance. However, in the case of a hospitalization due to a medical emergency, the insurer must be informed within 48 hours of getting admitted to the hospital.

4. Health Card or Policy Copy

   When you get hospitalized, you must show your health card or a copy of your mediclaim policy to the hospital authorities. These documents are issued by the insurer at the time of policy purchase.

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5. Pre-Authorization for Cashless Treatment

   Once you are admitted for cashless hospitalization, the hospital authorities will send a pre-authorization request to your insurer seeking approval for your cashless treatment. You will be required to fill out this form and submit it to the hospital. The hospital will verify your details and forward it to your insurer. Your cashless treatment begins as soon as your insurer authorizes your treatment.

   In case of a medical emergency, the hospital can begin your treatment immediately without waiting for pre-authorization from your insurer.

6. Hospital Billing and Exclusions

   On the day of your discharge from the hospital, your bill will be generated for the treatments and services availed. The bill will also include treatments that are not covered or excluded by your health policy. While most cashless health insurance plans cover a variety of medical conditions and emergencies, certain exclusions listed in the plan are never covered. For instance, HIV/AIDS, plastic surgeries, experimental treatments, non-medical expenses, injuries caused by terrorist acts, wars or illegal activities, etc., are excluded under most plans. Moreover, the insurer will not pay for treatments with an active waiting period.

   Hence, you will need to pay for all the treatments and expenses not covered by your insurance company.

7. Co-Payment

   In case your policy comes with a co-payment, you will have to pay that fixed percentage of the claim amount from your own pockets. The insurer is only liable to pay the remaining claim amount.

8. Settlement of Claims

   Your insurance company will review your hospital bill and crosscheck its details. Once satisfied, they will pay the bill amount directly to the hospital.

Benefits of Cashless Mediclaim Insurance

Take a look at the key benefits of cashless mediclaim insurance:

• More Convenient – Cashless insurance is more convenient as you do not need to make upfront bill payments. Thus, they do not have to worry about arranging money to pay the hospital bills.
• Access to Top-quality Medical Treatment – You can avail top-quality medical treatment at the best hospitals with cashless health insurance without worrying about its cost.
• Financial Protection – Cashless health insurance safeguards you against any emergency or unplanned medical expenses without the stress of arranging money to pay the hospital bills.
• Saves Time – If you have a cashless mediclaim policy, your claims will be settled much faster. This is because you do not have to file a reimbursement claim after paying the hospital bill and wait for your insurer to pay you the claim amount.
• Immediate Access to Emergency Healthcare – Cashless insurance enables you to obtain the necessary medical care immediately during an emergency without any delay due to arranging funds for bill payment.
• No Long List of Documents Required – While filing a cashless claim, you do not need to submit a long list of documents to your insurer. Instead, the hospital arranges all the documents and submits them to the insurer for pre-authorization.
• Stress-free Recovery – Cashless mediclaim insurance ensures your medical bills are taken care of by your insurer, allowing you to focus completely on recovery.

How to Initiate a Cashless Health Insurance Claim?

Follow the steps given below to initiate a cashless mediclaim:

Step 1: Inform your insurance company about your planned hospitalization at least 48 hours in advance and emergency hospitalization within 48 hours of getting admitted.

Step 2: Show your health card at the hospital and fill out the pre-authorization form.

Step 3: Submit your pre-authorization form to the hospital authorities, who will forward it to the insurer along with the required documents.

Step 4: Your insurer will verify the details on the form and approve/reject your pre-authorization request.

Step 5: If approved, obtain treatment at the hospital and sign all the documents at the time of discharge. Pay for all the expenses not covered by your insurer and your co-payment, if any.

Step 6: Your insurer will pay the remaining hospital bill directly with the hospital.

Step 7: If your cashless pre-authorization request is rejected, you can settle the bills after the treatment is over and file a reimbursement claim.