Cashless Mediclaim: Challenges

Experts always advise buying a health insurance plan which promises the benefit of cashless claims so that the financial burden to pay off the hospitalization bills does not fall on your shoulders. An average middle-class man finds it difficult to meet the huge hospitalization expenses associated with medical contingencies. This is the sole reason why a health plan is bought and the required premium is paid.

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    Though most plans offer cashless mediclaim and reimbursement claim settlement policy, reimbursement option is not favored because it involves the policyholders to pay the bills initially and then get it settled from the insurer. It is argued that a common man faces difficulty in meeting such expenses and so a cashless claim is better. However, a cashless mediclaim plan also has some challenges that make availing the claim a nightmare.


    A cashless mediclaim insurance plan has two concepts; one is the Preferred Provider Network (PPN), which is a hospital that is tied-up with the insurer to provide cashless treatments to the policyholder. The other concept is that of a Third Party Administrator (TPA) that is the mediator between the mediclaim insurance company and the policyholder and is responsible for the smooth settlement of claims.

    If a policyholder is admitted in a PPN hospital and identifies him with the TPA, he could avail of a cashless treatment and his hospital bills would be settled by the mediclaim insurance company directly without him having to shoulder the burden himself. This is the complete concept of a cashless hospitalization. However, this form of a claim settlement process is fraught with challenges and protocols.

    Challenges Involved in Cashless Mediclaim Insurance

    1. Getting a Part of the Claim Settled 

    A very common scenario is where the mediclaim insurer settles only a part of the total expenses incurred. For instance, you might be hospitalized for appendicitis for which the insurer is paying about Rs.25, 000. However, you develop a complication post-surgery which results in an extended hospital stay chalking up a total bill of Rs.40, 000, out of which the mediclaim insurer pays only Rs.25, 000 as cashless claim and the pending amount is later reimbursed.

    3. Not Getting the Facility of Cashless Treatment

    This happens mostly in emergency cases where the TPAs require time to facilitate cashless mediclaim treatment. In such cases, the insured or his family is asked to bear the costs and later get them reimbursed from the insurer despite the insured being admitted in a network hospital

    3. Excluded Treatments

    It is an obvious one because treatments which are excluded from the scope of your health plan would not be provided by your mediclaim insurer.

    4. The Document Jumble

    Availing cashless treatment requires adherence to documentation, especially the pre-authorization form which is to be submitted to the TPA to facilitate cashless treatment. Policyholders, being ignorant, fail to stick to the documentation, which results in difficulties in getting a cashless claim.

    You May Like to Read: How Does Cashless Mediclaim Work?

    How to Tackle Challenges Associated With Cashless Mediclaim Policy?

    There are some steps to be followed and rules to be remembered if you do not want to get embroiled in a difficult claim settlement process.

    These are

    • Check out the list of the PPN hospitals and always get admitted in a network hospital to ensure cashless mediclaim settlement.
    • A pre-authorization form is a mandatory requirement when it comes to availing a cashless claim. This mediclaim document needs to be filled and submitted with the TPA in a specified time frame. If the hospitalization is emergent, the form should be submitted within 24 hours of being hospitalized. In case of planned hospitalization, the form should be submitted at least 4-5 days in advance. Furthermore, the complete set of hospital bills should be submitted with the TPAs for a smooth mediclaim settlement process.
    • Always have the health card handy to be produced to the TPA for identification purposes.
    • Check the list of treatments that are excluded from your coverage before raising a claim.

    A cashless settlement, though convenient, has certain challenges when it comes to fulfilling the promise made. The challenges may stem from the fault of the policyholders, TPAs or hospitals. Passing the blame would be useless as the policyholder would be the one who ultimately suffers. You, as a policyholder, should take the precautionary measures to ensure adherence to protocols which would help you in getting a cashless settlement with ease and convenience.

    Written By: PolicyBazaar - Updated: 09 July 2021
    Disclaimer: Policybazaar does not endorse, rate or recommend any particular insurer or insurance product offered by an insurer.

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