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Cashless Mediclaim Policy- What You Should Know?

How many times do you remember getting a call from a relative or friend telling about an emergency hospitalization and need for cash? Many a times you run to the nearest ATM and withdraw money to get your family member admitted in a hospital. Cashless hospitalization is a service that is designed to avoid those tensed moments during hospitalization. All the medical bills are directly settled by the insurance company, provided the amount doesn't exceed the sum assured. There's just one catch to a cashless mediclaim policy, it can only be availed in network hospitals.

Cashless hospitalization is proving to be beneficial for users, especially  in emergency situations as a seriously ailing patient may not be able to arrange money before being treated. In addition, it is also very likely that he does not know many people in the city. A cashless hospitalization can simply solve this situation.

Cashless Mediclaim Policy helps you in dealing with medical emergencies by paying your hospitalization expenses upfront. Compare and choose the best plan at PolicyBazaar.

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Types of Cashless Health Insurance in India:

There are many types of cashless health insurance in India which can be broadly classified into following categories:

1. Cashless Family Health Insurance

This is the cashless family health insurance policy where sponsor owns the policy and the people covered under it are called its members. One can get his whole family covered under one policy named family health plan.

2. Cashless Health Insurance for Senior Citizen

This is the cashless health insurance for senior citizens who cover hospitalization expenses, ambulance charges, and pre-existing diseases subject to terms of the policy.

How Cashless hospitalization Works?

Health insurance companies tie up with different hospitals after checking quality of their medical services and negotiating rates for different procedures. These hospitals are known as network hospitals and when you get hospitalized in any one of them, you do not have to settle the bill with the hospital. Your insurance company that is represented by TPA (third party administrator) will coordinate and settle the bill with the hospital.

Basically, there are two ways through which you can avail cashless hospitalization-

1. Planned Hospitalization

You know beforehand that you will be hospitalized in next few days and it means, you have ample time to decide from which hospital you want to avail services.

Here is what you need to do- 

      • Read your health insurance policy or call on the toll free number of insurance company to know nearby network hospital.
      • Once you have finalized the network hospital, take your policy card to the hospital and ask for a pre-authorization form, which you can get from the insurance desk at hospital or you can also download it from the TPA’s website. Usually, the first part is filled by the patient, while the other part is filled by attending physician.
      • Submit your form at the insurance desk, where it will be scrutinized to ensure its authenticity.
      • Then the form will be faxed to the TPA who will process it and either approve or reject it
      • If your form is approved then TPA will send authorization letter detailing the sanctioned amount for the treatment.

2. Emergency Hospitalization

This is where you need immediate medical care. You should make sure that you initiate the cashless mediclaim facility within 24 hours of hospitalization. 

Things you will need to do are-

      • Show your health insurance card at the hospital, which will contain your policy number, name of your insurance company and the type of health policy you are holding.
      • Fill in the pre-authorization form after which the person at the insurance desk will expedite your claim process. However, if you can’t wait for the TPA approval, you can pay hospital bills and later reimburse it from your insurance company.

The protocol says that in emergency conditions, a TPA should process a claim within 6 hours.

Read In Detail: How Does Cashless Mediclaim Work

What is Not Paid in Cashless health insurance?

There are some expenses which are not even covered by cashless hospitalization-

      • Attendant/Visitor fees
      • Ambulance charges
      • Toiletries
      • Service charge
      • Expenses for oxygen mask, diapers, nebulizers, etc.
      • Documentation charges

Top Reasons For Claim Rejection in Mediclaim Policy

Wondering why your claim is rejected by the insurance company? We have listed below some of the top reasons of rejection-

      1. If the illness for which you have been hospitalized is not covered by your insurance policy
      2. If you exhausted entire sum assured for that period
      3. If the information contained in the pre-authorization form is insufficient to approve the claim
      4. If the information provided on the pre-existing ailment is insufficient in the pre-authorization form
      5. Delay in intimating TPA about hospitalization

“TPAs cannot reject or partially disallow claims”= Bombay High Court

The Bombay High Court has held that decisions to reject or partially disallow health insurance claims are to be taken by insurance companies and not by TPAs who offer various services to policyholders on the behalf of insurance companies. The move is likely to bolster the claim process because it has been seen that TPAs are given incentives by insurance companies to reject claims and in their attempt to earn incentives, TPAs reject claims at the first stage.

Points to Remember before buying Cashless Hospitalization Plan

      1. Cashless hospitalization is available only at network hospitals
      2. It is the hospital responsibility to give a justification of the treatment you are undergoing
      3. Remember to keep a photocopy of all documents, including medical bills, lab reports, claim form and discharge papers
      4. Remember to carefully read terms of your cashless policies because there are many conditions that could make you ineligible to avail cashless hospitalization
      5. Usually, an insurance company agrees to pay part of the sum required for the treatment of the patient. In some cases, if the policyholder exceeds the sum assured, then the policyholder will require to pay the excess amount

Future Insights of Cashless Insurance

Recently, health insurance companies are lining up cashless OPD to make life easier for patients. It means now patients don’t need to be hospitalized for minimum 24 hours to avail cashless hospitalization. Apollo Munich’s Maxima is offering vouchers for consultancy and pharmacy and similarly, ICICI Lombard is also planning to launch cashless OPD product.

Don’t Put Your Health at Stake, Trust Only Leader When it Comes to Choosing the Cashless Mediclaim Procedure

Making the complicated insurance comparison an uncomplicated process, the team at PolicyBazaar is at its best when it comes to finding a right cashless hospitalization plan. By entering basic details like name, age, annual income, etc, you will be able to get mediclaim quotes at free of cost!

Compare health policies from various providers at PolicyBazaar and ensure that you get the right cover for yourself and your family.

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