How do cashless claims work in health insurance

When you buy a health insurance policy, one of the most important features to look out for is the facility to make a cashless claim. Today, all most all health insurance companies provide the advantage of health insurance cashless claims making it very easy and convenient for an insured to get the best possible treatment without worrying about high-cost treatment. While cashless claims are quite straightforward, as a policyholder, it is your responsibility to understand how cashless claims work in health insurance.

Benefits of Cashless Health Insurance Claims

When you buy a health insurance policy, the insurer offers you a list of hospitals and healthcare centres, called network hospitals, where you can seek treatment without having to pay upfront. These hospitals/ healthcare centres have a partnership with insurers. In the case of your hospitalisation, the insurer would settle your hospital bills with the hospital directly. You would only have to pay for your share in the form of a deductible, and the uncovered expenses, if any. Let’s us take a look at the working of a cashless claim in more detail.

In case there is a medical issue, and you need to be hospitalised, you would have to get admission to a network hospital. In case of planned hospitalisation, it is recommended that you inform the insurer at least 2 to 3 days in advance so that the pre-authorisation procedure can be completed. In case of an emergency, a family member/ friend can notify the insurer, preferably within 24 hours of your admission. The pre-authorisation form can be filled in and submitted to the hospital help desk.

There are some insurance companies that have an in-house claim settlement department, while some companies have TPAs, Third Party Administrators to handle the claims. Once your treatment is complete, at the time of discharge, the company/ the TPA will complete most of the paperwork on your behalf and also pay the medical bills. You will be informed about your share of the bill, if any, which you would have to pay from your pocket.

Keep in mind the following points when you seek to raise a cashless claim:

1. A cashless claim does not mean that you do not have to pay any money to the hospital. As explained above, you would have to pay your share, if any

2. A health insurance cashless claim can only be made if the treatment is sought in a network hospital

3. In case you have taken treatment in a non-network hospital, you can still raise a claim. However, you would have to pay the bills upfront and then seek a reimbursement

4. Make sure to inform the insurer about the hospitalisation in time for a smooth and hassle-free claim

5. Policy exclusions are not included in a cashless claim.

When choosing a health insurance provider, it is important to see that they have a wide network of hospitals. However, you should also keep in mind that there should be enough hospitals in your vicinity/ city so that in case you need hospitalisation, you can timely reach the hospital. In case there is a particular doctor/hospital where you wish to get treated, make sure you choose a policy where you can get the required coverage and enjoy the benefit of making a cashless claim.

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