How Does Cashless Mediclaim Work?

Most of us take care to select a good insurance policy that will sufficiently safeguard our family’s medical requirements. However, we often tend to overlook the nuances involved in opting for a conventional reimbursement facility, where the insurer reimburses the policyholder for medical expenses incurred after treatment has been completed. This means that the policyholder not only pays out of their pocket during the treatment, but that if they do not provide the necessary paperwork or formalities as per the requirements of the insurer, they might not even be reimbursed by the insurance provider.

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    This is why cashless mediclaim policies are a better choice. Under this facility, the policyholder does not have to pay for the medical expenses out of their pocket. Instead, they have to notify the insurer that they would be availing of medical care, who would then manage the expenses directly with the medical centre during the course of the treatment. In other words, even if the policyholder does not have the money for medical treatment during emergencies or when medical attention is required, cashless mediclaim covers their medical and hospitalization needs.

    Cashless mediclaim is a type of benefit within medical insurance and can be availed of within an individual or family floater policy. Here is how the cashless mediclaim facility works –

    Network of Hospitals

    The most important aspect to cashless mediclaim is the network of hospitals, failing which, it cannot be availed. Insurance companies tend to have a direct network with a certain list of hospitals. If the policyholder avails of medical care in a facility that is not listed under the network of hospitals, then they cannot avail of cashless mediclaim for that particular round of treatment.

    Planned Claims

    When the policyholder is aware that they would be undergoing treatment, they have to inform the insurer in advance, as per the stipulations of the policy. The insurer will then bear the pre and post hospitalization expenses in due course. The policyholder thus needn’t have to bear any expenses up to the number of days that are mentioned in the policy. The pre-authorization form would require information and history about the illness, the line of treatment and the approximate duration of hospitalization and expected expenses.       

    Emergency Claims

    There are often situations where unplanned expenses crop up, in the case of a medical emergency, accident or grave illness. The insurer can avail of cashless mediclaim under such circumstances as well by informing the insurer accordingly. The insurer should read the terms and conditions mentioned in the policy and provide the necessary documentation under both cases, so that they can enjoy the maximum benefit of cashless mediclaim. Most emergency claims usually have an intimation deadline mentioned in the policy application documents.      

    Exclusions

    While most cashless plans cover most medical conditions and emergencies, there are some temporary and permanent exclusions that are listed in the plan that the policy will never cover. They could be pre-existing illnesses, HIV/AIDS, routine medical check-ups, dental procedure, experimental treatments, non-medical expenses or injuries caused by terrorist acts, wars or during illegal activities.

    However, cashless mediclaims do cover benefits like ambulance charges, critical illnesses, pre and post hospitalization  medical expenses and in-patient care, to name a few.

    Between the reimbursement and cashless route, the latter is generally the more favourable option, given that the policyholder can avail of medical treatment even if they do not have the funds for the same. This is particularly beneficial in the case of those do not have a fixed income. Apart from that, various policies offer a myriad of advantages like transfer of policy from one policyholder to another, cashless mediclaim that is valid outside India. Cashless mediclaim also provides tax benefits and can be renewed every year throughout the lifetime of the policyholder.

    Written By: PolicyBazaar - Updated: 29 July 2021

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