Cashless claims in Health Insurance

What are cashless claims?

All medical insurance promise cashless claim if treatment is taken in a network hospital. In cashless claims, your insurance company will directly settle your medical bills with the network hospital. You do not have to pay out of your pockets. You just have to inform your insurance company and take treatment from a network hospital as per the terms and conditions of your policy.

Can a cashless claim get rejected? Why do they get rejected?

You should know that even cashless claims can get rejected. The reason can be:

1. Treatment taken from a non-network hospital: Cashless claim facility exists only when hospitalization and treatment were taken from a network hospital. It does not apply to the cases where you were admitted to a non-network hospital and taken the treatment from there itself. But you can ask for a reimbursement claim.
2. Improper documents: If the network hospital does not submit documents as per the agreed arrangement, your claim can get rejected. Mostly, network hospital has an understanding but sometimes casual approach is taken and proper documentation is not done.
3. Undesired hospitalization: In many cases, patients and hospitals prefer taking treatment in hospitals just because of the insurance facilities. In cases, where it is proved that hospitalization was not desired, a claim can be denied.
4. Non-disclosure of facts: Concealment or false disclosure of information might lead to claim rejection.
5. Failed to take prior approval: You need to take an advance approval for a cashless claim. The claim will be rejected if approval was not taken. 
6. Failed to update details: If you fail to update your contact details like address, phone number and e-mail, then your claim might get rejected.

What to do if your cashless claim gets rejected?

If your health insurance cashless claim gets rejected and you feel that your claim is genuine then you can apply for a reimbursement.

Reimbursement

In reimbursement, the insured pays all the medical bills and other costs involved with hospitalization and treatment from his pocket and then applies for a claim from his insurance company. The insurance company will investigate the case. It will verify the medical reports and details of the bills and then decide whether to approve the medical reimbursement claim or reject it. If they reject it, they will notify you of the reason for rejection.

Here is a similar case of cashless claim rejection resolved by Insurance Samadhan

Miss Sandeepa bought a health insurance policy for her parents in 2020. In January 2022, her father experienced chest pain and was breathless. They visited the hospital for a check-up. The initial ECG showed some deviations and an echo showed an LVEF of 35%. He was diagnosed with CAD-DVD and admitted to the hospital.

Miss. Sandeepa applied for a cashless claim, but the claim was rejected based on some doubts about hypertension. She stated that his father had no episode of hypertension in the past. 

She paid for the treatment from his pocket and applied for a reimbursement claim. She submitted all the documents for review, but the reimbursement claim was rejected. For over 5 months, she had an email trail with the insurance company, but nothing happened. She lost all her hopes.

Then, she learned about Insurance Samadhan and reached out to us on March 21, 2022. We took her father’s case after understanding and verifying every detail of the case. She found us supportive and helpful. We helped her with every step of the procedure. By July 04, 2022, we were able to resolve her case and get the reimbursement money. 

If you have any complaints related to insurance, we’ll be happy to give you our guidance. 

Click on the below links to read some cases resolved by Insurance Samadhan:

Health Claim Rejection amid Covid-19

Mis-selling in a life insurance policy