Cashless Health Insurance

With growing medical costs in India, treatments for major diseases and illnesses have become much more expensive. This can cause financial hardships for many people who are already struggling to make ends meet. There is a growing number of patients who are unable to afford to pay for the services that they feel are important for their health. This has led to the growth of cashless health insurance plans.

Cashless health insurance plans are those medical insurance policies where the insured individual does not need to pay any out-of-pocket expenses in order to receive treatment from any network hospital. This article will offer everything you need to know about cashless health insurance plans in India.

Health emergencies are often unexpected and unplanned. People do not recognise they have a disease until it has progressed to the point where they have to be hospitalised. In such a case, paying overdue medical expenses might have a negative impact on your financial stability. Nevertheless, cashless health insurance eliminates the need for you to face such hurdles.

Since the hospital invoice and other medical bills are settled by the insurance provider directly with the medical facility, you do not need to pay any out-of-pocket expenses other than any co-pay, deductible or non-covered expenses. This is extremely useful in situations where the treatment expenses surpass the amount that the insured can spend at the time.

Here is details of some popular cashless health insurance plans:

1). Apollo Munich Optima Restore Health Insurance

Rebranded as HDFC ERGO health insurance, HDFC ERGO Optima Restore health insurance plan is an indemnity health insurance policy which offers sum insured from 3 lakhs to 50 lakhs at both individual and family floater basis.

• Sum insured: INR 3 lakhs, 5 lakhs, 10 lakhs, 15 lakhs, 20 lakhs, 25 lakhs and 50 lakhs
• Policy type: Individual / Family floater
• Policy term: 1 year or 2 years
• Entry age: 91 days to 65 years

Coverage:

• In-patient treatment expenses
• Pre-hospitalisation expenses (subject to a limit of 60 days)
• Post-hospitalisation expenses (subject to a limit of 180 days)
• Daycare treatments
• Organ donor expenses
• Domiciliary treatments
• Daily cash benefit for shared accommodation (subject to a limit of INR 800 or 1000 per day for 6 days based on the chosen sum insured)
• Ambulance expenses (subject to a limit of INR 2,000 for road ambulances and INR 2.5 lakhs for air ambulances available for policies with over 5 lakhs sum insured)
• Critical illness e-opinion (available once per policy year)
• Restore benefit
• Unlimited restore benefit (available as an optional benefit)
• Health check-up benefit for individual policy (subject to a limit of INR 1,500 to 5,000 based on the chosen sum insured)
• Health check-up benefit for family floater policy (subject to a limit of INR 2,500 to 10,000 based on the chosen sum insured)

2). Care Health Plan

Care health plan is an indemnity medical insurance policy with sum insured ranging from INR 3 lakhs to 75 lakhs. The policy is available only on a family floater sum insured basis.

• Sum insured: INR 3 lakhs, 4 lakhs, 5 lakhs, 7 lakhs, 10 lakhs, 15 lakhs, 20 lakhs, 25 lakhs, 30 lakhs, 40 lakhs, 50 lakhs, 60 lakhs and 75 lakhs.
• Policy type: Family floater
• Policy term: 1, 2 or 3 years
• Entry age: 91 days for children with one individual of 18 years or above covered. 5 years for other cases.

Coverage:

• In-patient hospitalisation
• Pre-hospitalisation expenses (subject to a limit of 30 days)
• Post-hospitalisation expenses (subject to a limit of 60 days)
• Daycare treatments
• Daily allowance benefits (subject to a limit of INR 500 per day for 5 days)
• Ambulance expenses (subject to a limit of INR 1,500 to INR 3,000 per hospitalisation based on the amount of sum insured)
• Domiciliary hospitalisation
• Organ donor expenses (subject to a limit of INR 50,000 to INR 3 lakhs based on the amount of sum insured)
• Annual health check-up benefit
• Second opinion benefits
• Sum insured recharge
• Care anywhere benefit (available in policies with a sum insured of 50 lakhs or over)
• Maternity cover (available in policies with a sum insured of 50 lakhs or over)
• Alternative treatment

If you are looking for the best health insurance policy that offers cashless facility, these plans are a good place to start. However, it is recommended to compare health insurance plans in India before you get it. Whenever you do decide to buy health insurance online, it should be able to provide you with the highest coverage within your budget restrictions.

A cashless health insurance policy is one where the insured's medical bills are immediately reimbursed between the insurance provider and the partnered medical facility. It offers cashless hospitalisation, which means that the insured does not need to spend cash to receive care. Nevertheless, cashless health insurance policy healthcare is only provided in the insurance provider's network hospitals and medical facilities.

The salient features of cashless insurance policies are decided by insurance companies and, therefore, vary between insurers and insurance policies.

• You don’t have to pay any money at any of the network hospitals
• Covers all pre and post hospitalization expenses
• NCB - No Claim Bonus
• Includes expenses related to in-patient hospitalization for more than 24 hours
• Hospital Daily Cash benefit is available
• Provides cover for emergency ambulance expenses, domiciliary treatment, organ transplant, etc.
• Provides complementary one time medical check-up and diagnostic test

• Provides a robust corpus for medical emergencies: Medical emergencies, whether unforeseen or not, burn a hole in our pocket when we don’t financially plan for them in advance. Cashless claims are even more beneficial as it saves critical time that a patient’s family requires to arrange for hospital expenses. Instead, they can get the necessary treatments started simply by showing their cashless health insurance policy card to the relevant hospital authorities.
• A source of relief: A cashless health insurance policy gives you the assurance that finance would not be a concern for you, in case the need arises. You can get admission to hospitals and start the necessary treatment without any delay through a hassle free cashless claim. You can solely focus on the treatment and recovery without finance being a cause for worry.
• Extensive range of coverages: Cashless health insurance policies generally include comprehensive coverages like pre and post hospitalization expenses, ambulance expenses, inpatient care, domiciliary treatment, etc. Certain cashless health insurance plans also offer health check-ups and diagnostic tests at regular intervals.
• Safeguards your health during travels: The uncertainties of a new location often prevent you from accessing the right treatment, in case a medical emergency arises while you are traveling. Being the holder of a cashless health insurance or cashless medical insurance assures you of reliable medical services at a network hospital, and that too, without the hassle of arranging for hospitalization and medical expenses.
• Tax benefits: Premium payments made towards cashless health insurance policies are eligible for tax benefits under Section 80D of the Income Tax Act 1961, up to Rs.25,000 for individuals below 60 years of age and up to Rs.50,000 for senior citizens.

Here is a step-by-step procedure for availing cashless health insurance claim filing:

1). Planned Hospitalisation

• Choose a network hospital where you will be admitted.
• Connect with the insurance provider and inform them about your hospitalisation.
• Visit the hospital a minimum of 3 days before hospitalisation and offer your insurance health card to the TPA in the hospital.
• You will also need to fill up a cashless claim application.
• The paperwork will be sent to your insurance provider for authorisation.
• Following your treatment, your hospital invoice and other medical bills will be forwarded to your insurance company.
• The insurance company will go over the documents and either verify or deny your claim.
• If your claim is accepted, the insurance company will connect the hospital and settle all the charges directly.

2). Emergency Hospitalisation

• Choose a network hospital where you will be admitted.
• Connect with the insurance provider and inform them about your hospitalisation within 24 hours.
• Offer your insurance health card to the TPA and fill up a cashless claim application.
• The paperwork will be sent to your insurance provider for authorisation.
• Following your treatment, your hospital invoice and other medical bills will be forwarded to your insurance company.
• The insurance company will go over the documents and either verify or deny your claim.
• If your claim is accepted, the insurance company will connect the hospital and settle all the charges directly.

Health insurance companies collaborate with hospitals across locations in India to prepare a list of network hospitals. Policyholders of cashless health insurance plans, on getting hospitalized at any of these network hospitals for any medical treatment, would be eligible for availing cashless claims whenever the need arises. The medical expenses incurred up to the applicable sum insured will be paid by the relevant health insurance company directly to the hospital.

• Sum insured : The sum insured that will be suitable for you depends on the city that you belong to. While for a small city, a sum insured of between Rs.3 lakhs and Rs.5 lakhs is believed to be a good amount, a sum of at least Rs.5 lakhs will be essential for metro cities.
• Claim settlement ratio: Claim settlement ratio of health insurance companies is one of the most essential factors that you should check before taking a final decision. The higher the ratio, the greater are your chances of a quick and hassle free claim settlement process.
• Network hospitals: Cashless insurance can be claimed only at network hospitals of a health insurance company. Assess the list of network hospitals and check whether they include ones in and around your locality and/or the ones that you usually visit. Also, ensure that you will be able to avail cashless claims across locations in India.
• Pre and Post Hospitalization: There are certain medical expenditures that are incurred before and after hospitalization. These include medical check-ups and follow-ups, diagnostic tests, recovery treatments, etc. Only expenditures related to the treatment for which the individual had to be hospitalized is considered.
• Co-payment: Co-payment implies the pre-determined percentage of the claim amount that you have to bear, while the rest will be borne by the insurance company. This is a common clause of group and individual/family health insurance policies of most insurance companies.
• No Claim Bonus: Several insurance companies offer a No Claim Bonus when the cashless health insurance policyholder has not made a claim. In such an event, either the premium is reduced or the sum insured is increased or both.
• Day care coverage: Traditional health insurance policies make it mandatory for individuals to be hospitalized for at least 24 hours to be eligible for this coverage. However, due to advancement in medical technology there are many treatments which do not require 24 hr hospitalization and are covered under the head of Day Care Treatment. Cashless health insurance from most insurance companies include this benefit. Make sure that your cashless health insurance policy includes this feature.
• Maternity Benefits: Check for the waiting period for claiming maternity expenses. This will keep women covered against maternity expenses, enabling them to tide over the inflationary effects on such expenditures.
• Free medical check-up: It is best to opt for a cashless health insurance policy that offers free medical check-ups and diagnostic tests.
• Lifetime Renewal: This feature in a cashless health insurance policy eliminates the hassle of renewing it annually. The fact that it covers individuals across ages proves to be beneficial for you, especially if you have elderly dependent parents in your family.

Planned hospitalization implies that you are aware that you will be hospitalization in a few days and, therefore, you have some time on your hands to make certain arrangements. Here’s what you should do before a planned hospitalization with a cashless health insurance policy:

• Go through the cashless health insurance policy document or call the customer care number of your insurance company to become aware of the list of network hospitals.
• After you have decided on the network hospital where you would like to be treated, you need to fill up a pre-authorization form. You can get this form from the insurance desk at your chosen hospital or download it from the TPA website. The first section of the form has to be filled up by you, while the second half is meant for the attending physician.
• Complete the form with accurate details. Ensure that there is no suppression or misrepresentation of information. After submission, the hospital authorities will evaluate the authenticity of the details provided in the form.
• This form is then faxed to the TPA, which will either approve or reject it.
• If your application is approved, the TPA will send the authorization letter back to your chosen hospital, along with details about the sanctioned amount that they will provide for your medical treatment.

When you require emergency medical treatment, you have to initiate the cashless health insurance facility within 24 hours of hospitalization.

• Show the cashless card for health insurance to the relevant hospital authorities at the time of hospitalization. This card comprises of the name of your insurance company, your policy number and the type of health insurance plan that you have opted for.
• Fill up and submit the pre-authorization form, available at the insurance desk, after which the claim settlement process will be expedited. Under emergency medical situations, it is mandatory for the TPA to process claims within 6 hours of it being initiated by the cashless health insurance policyholder or his/her family. However, if you prefer not to wait for the approval for TPA, you can pay your hospital bills, and later initiate the claim settlement process to get your reimbursements.

The growth of cashless health insurance plans in India will help to ensure that more people can get the medical treatment they need. Whether you need surgery, diagnostic tests or any other kind of health care, a cashless health insurance plan will provide the coverage you need without putting your finances at risk.

So, if you do not have proper health insurance coverage in place, it is advisable to shop around for the best health insurance plan in India. The best health insurance in India offers both cashless, and reimbursement claims to the insured, which makes them incredibly valuable in medical emergencies.