Cashless Health Insurance

What is Cashless Health Insurance?

Cashless Health Insurance refers to a mediclaim policy in which the medical expenses of the insured is directly settled between the insurance company and the network hospital. It provides cashless hospitalization facilities where the insured does not have to pay cash to avail treatment. However, cashless health insurance can be availed only at network hospitals of the insurance company.

A cashless health insurance policy helps the insured to deal with medical emergencies efficiently. It also allows the insured to focus only on the treatment as the hospitalization expenses are taken care of by the insurance provider.

Types of Cashless Health Insurance in India

Broadly, there are three types of cashless health insurance in India, which are as follows:

1. Cashless Family Health Insurance

Under this cashless family health insurance policy, the whole family of the policyholder can avail cashless treatment under one policy.

2. Cashless Senior Citizen Health Insurance

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

3. Cashless Critical Illness Health Insurance

A cashless critical illness health insurance policy provides cashless treatment to people suffering critical illnesses, such as cancer, heart attack, etc.

Why is It Important to Have Cashless Health Insurance?

Cashless health insurance is necessary at times of a health emergency when you might be cash strapped or do not have immediate access to cash. It is designed to eliminate any form of cash payment to avail medical treatment on time. It also allows people to avail the best quality medical treatment without worrying about arranging money to pay the hospital bills.

How Does Cashless Health Insurance Works?

Cashless health insurance basically removes the hassles of having to pay cash at the hospitals at the time of need. For cashless health insurance, insurance providers enter into direct negotiations with hospitals in their network to pay for the treatment availed by the insured person. They tie up with these hospitals, which are then known as the network hospitals of the insurance company. 

When the insured gets hospitalized in a network hospital, he/she does not have to settle the bill with the hospital at the time of discharge. Instead, the insurance company or their TPA (third party administrator) will coordinate and settle the bill directly with the hospital.

Moreover, health insurance companies are now also offering cashless OPD facilities to the insured. It means that now patients don’t need to be hospitalized for a minimum of 24 hours to avail cashless hospitalization services.

How to Avail Cashless Hospitalization?

Basically, there are two ways through which cashless hospitalization can be availed:

1. Planned Hospitalization

Planned hospitalization is when you know beforehand that you need to get hospitalized in the next few days. In this case, you have to choose a network hospital to avail cashless services. Follow the steps to avail cashless hospitalization in case of a planned hospitalization: 

• Call on the toll-free number ofthe insurance company to know about the nearby network hospital.
• Once you have finalized the network hospital, take your policy card to the hospital and ask for a pre-authorization form.You can get this form from the insurance desk at the hospital or download it from the insurer’s website.
• Submit your form at the insurance desk, whichwill 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 pre-authorization requestis approved, then TPA will send an authorization letter detailing the sanctioned amount for the treatment.

2. Emergency Hospitalization

In the case of emergency hospitalization, you need immediate medical care and thus, you should initiate the cashless mediclaim facility within 24 hours of hospitalization. This is how cashless hospitalization can be availed:

• Show your health insurance card at the network hospital, which will contain your policy number, the 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, get them reimbursed from your insurance company.

As per the protocol in emergency conditions, a TPA should process an emergency hospitalization claim within 6 hours.

What is Not Covered in Cashless Health Insurance?

There are some medical expenses, which are not covered by cashless health insurance. Take a look at them below:

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

Things to Keep in Mind Before Buying a Cashless Health Insurance Plan

Here are a few things that you should keep in mind while availing cashless hospitalization facility through a cashless health plan:

• Cashless hospitalization is available only at network hospitals.
• It is the hospital’s responsibility to give a justification of the treatment you are undergoing.
• Remember to keep a photocopy of all documents, including medical bills, lab reports, claim form and discharge papers before leaving the hospital.
• Your cashless insurance claim can also be rejected. Make sure that the information provided in the preauthorization form is complete to prevent rejection by the TPA.
• Remember to carefully read all the terms of your cashless health policy because there are many conditions that could make you ineligible to avail cashless hospitalization.
• Usually, an insurance company agrees to pay a part of the sum insured required for the treatment of the patient. In case the policyholder exceeds the sum insured, then the policyholder will have to pay the excess amount.
• Not all medical expenses are covered under cashless health insurance.

Top Reasons for Claim Rejection in a Cashless Mediclaim Policy

Given below are some of the top reasons for cashless health insurance claim rejection:

• If the illness for which you have been hospitalized is not covered by your insurance policy
• If you have exhausted the entire sum insured for the given policy tenure
• If the information given in the pre-authorization form is insufficient to approve the claim
• If the information provided on the pre-existing ailment is insufficient in the pre-authorization form
• Delay in intimating TPA about hospitalization

However, according to a ruling by the Bombay High Court, the decision to reject or partially disallow health insurance claims can be taken only by insurance companies and not by TPAs who offer various services to policyholders on their behalf.

How Can Policybazaar Help to Choose a Cashless Health Insurance Policy?

Making the complicated insurance comparison an uncomplicated process, Policybazaar offers the best assistance when it comes to finding the right cashless health insurance plan. By entering basic details like name, age, annual income, etc. on Policybazaar.com, you will be able to get mediclaim quotes free of cost. Moreover, you get to compare health policies from various insurance providers at Policybazaar.com and ensure that you get the right cover for yourself and your family.

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