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Know-How About Cashless Hospitalization

Apart from all the emotional suffering, an out-of-the-blue medical emergency can dig deeper into your lifetime savings. This is precisely why you must invest in a good health insurance policy to ensure that you get sufficient financial aid during any kind of emergency.

While a health insurance policy does provide you coverage against hospitalization costs, you might still be required to pay for it from your own pocket before raising a claim. This may not be the most ideal situation for people with no extra savings to shell out.

This is where cashless hospitalization plays a saviour.

What is Cashless Hospitalization?

With the alarming rate of inflation and upsurge in medical expenses in India, hospitalization and all the associated treatments are becoming costlier. Unless you were born with a silver spoon, you need to pre-plan to tackle any medical emergency. Health insurance policy, supplemented with cashless claim settlement, is one such element that needs to secure a place in your financial plan.

In short, if you are admitted in the hospital but do not have any emergency funds to pay off for your hospital bills, then the cashless hospitalization acts as your saviour. If you inform your insurance company about your hospitalization, they would directly settle the bills with the hospital rather than you having to first pay the expenses and then wait for your insurer to reimburse the money to you.

cashless hospitalization cost

Cashless health insurance policies are designed with the sole intention of providing the much-needed financial relief to the policyholder at the crucial time of hospitalization. It is an arrangement of the insurance companies and their network hospitals, where the claims are settled without involving the insured. Under this arrangement, Third Party Administrator (TPS) acts as a bridge between the hospitals and the insurance company in settling the claims. In most cases, these TPAs set up a desk at the network hospital to facilitate smooth processing of such claim requests.

Cashless Claim Settlement Can Be Opted For

Planned Hospitalization

For the treatment of a pre-existing disease

Every insurance company is in a tie-up with certain hospitals that form a part of their Preferred Provider Network or PPN. When you plan to get treated in such hospitals, you can avail the cashless claim settlement facility. To avail it, you need to do the following:

  • Fill a detailed claim form with all the information pertaining to the impending hospitalization.
  • Send or Email the form to the insurance company/TPA for their approval.
  • Post-approval, the TPA or insurance company then notifies the hospital regarding the approved amount.
  • The TPA or insurance company directly settles the expenses with the hospital after the treatment is done.

Emergency Hospitalization

For an unexpected event like an accident or a critical illness

In an unforeseen situation like an accident or a critical illness, if hospitalization is required, then the policyholder or his/ her family members should follow the following procedure:

  • Within 24 hours of hospitalization, intimate the insurance company/TPA. Also, send along the claim form.
  • After a detailed review of the form, the TPA/insurance company decides to approve or reject the cashless settlement request.
  • The decision is then duly communicated to the policyholder/contact person and the treating hospital.

Points To Be Noted

  • Cashless service is available only at the network hospitals.
  • If the request for cashless settlement is denied, you can still pay for the expenses at the hospital from your pocket and then request for reimbursement.
  • To avail the cashless facility, it is important to send a timely intimation to the insurance company/TPA.
  • If the total cost of treatment exceeds the initial approved amount, the hospital can request the TPA or the insurance company to enhance this amount as per the expenses.
  • All the necessary documentation, prescriptions and doctor’s reports should be furnished, if required by the insurance company/TPA.
  • Always share a copy of your health insurance documents and identity card with your family/friends/relative for timely use. It is mandatory to display the health insurance card at the time of admission in the hospital to avail cashless settlement.
  • Cashless settlement of claims is purely subject to terms and conditions mentioned in the policy wordings.

What's Not Covered in a Cashless Health Insurance?

While your health insurance policy tackles any financial blows resulting out of hospitalization, there are certain items that are not claimable in spite of being a part of your medical expense. Some of them are mentioned below:

  • Admission or registration fees
  • Toiletries
  • Service Charges
  • Attendant's fees
  • Expenses pertaining to diapers, oxygen masks, syringes, etc.

Also Read: Do's and Don'ts a Policyholder Must Know While Buying Cashless Health Insurance

Planning to Buy a Cashless Health Insurance Policy?

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FAQs on cashless health insurance

I live in Ajmer, how can I know the hospitals that will allow cashless treatment?

The detailed list of all the network hospitals is available with your insurance company. If you have still not received the same, please contact your insurance company for an update. Simultaneously, you can also access this information through the online portal of your insurer.

What could be the possible reasons for denying my request for the cashless settlement?

As per the strict IRDAI guidelines, the insurance company/TPA cannot deny your request for cashless treatment unless there’s a valid reason to do so. Some of these reasons could be that:

  • The hospital you are seeking/planning to seek the treatment from is not part of preferred provider network.
  • The ailment you are seeking/planning to seek the treatment for is beyond the scope of coverage of your insurance policy.
  • The information mentioned in the request form is incomplete or insufficient.
  • You have already used the entire sum assured for that year.

Can I opt for cashless treatment for OPD Procedure?

Because OPD treatments are not covered in your health insurance policy, you cannot opt for cashless treatment for them. However, if it’s a part of hospitalization that is covered by the insurance company, you can claim the amount.

I am soon to deliver a baby, can I request for a cashless settlement?

Congratulations and all the best! The good news is – yes, you can opt for the cashless treatment. You will have to refer to your policy wordings to check the waiting period and the scope of coverage related to maternity.

I have lost my health card, can I still opt for cashless treatment?

If you have lost your health card, you should intimate your insurance company/TPA as soon as possible. Further, it's entirely at the discretion of the insurance company/TPA to accept or reject your request for cashless treatment. Some TPAs/insurers allow their policyholders to proceed with treatment on the basis of KYC documents, if the health card is not available.

Cashless settlement of hospitalization expenses is one of the biggest advantages of health insurance. In times, when you are already emotionally fragile, what can be more comforting than a financial respite to reduce your worries and stress?