How to Avail Cashless Claim for a Health Insurance Policy?

The purpose of health insurance is to avail of monetary support during the period of treatment in the hospital. Health insurance is an indemnity product which means that the insurance company indemnifies the monetary expenses incurred on account of medical treatment. It also means that the insured cannot take any gain out of such an arrangement. Health insurance claim can be availed through reimbursement or a cashless facility. Cashless is a smooth system where the insurance company directly pays the hospital without any monetary pressure on the family of the insured. However, insurance companies or TPAS work with selected hospitals screened on various parameters. It is necessary for all customers to identify the network hospital and visit such hospitals only for cashless treatment.

How to Avail Cashless Claim for a Health Policy?

Planned Hospitalization

If beforehand, you are aware of the hospitalization, then take the following steps:

1. Identify a network hospital.
2. Submit your policy document along with the doctor’s prescription advising admission. Also, carry at least 3 copies of the ID card like Aadhar of the patient. The help desk would verify the ID before forwarding the documents.
3. Network hospital has a desk that will guide you to take approval for the planned surgery.
4. The insurance company may seek additional information from you or through the help desk. After scrutiny, the insurance company would either approve/reject or seek more information.
5. If approved, then submit the letter of confirmation along with the health card to the hospital at the time of admission.

Unplanned or Emergency Hospitalization

In case of an unplanned or emergency hospitalization, follow the below steps:

1. Within 24 hours of the admission, intimate the insurance company. You need to submit the necessary documents like a copy of the insurance policy, ID proof with photo, address proof, etc.
2. A claim intimation or reference number will be generated by your insurance company.
3. The hospital will fill out the cashless claim form and submit it to the insurance company.
4. The insurer will issue an authorization letter to the hospital. If the company rejects the claim, then you will be notified about the rejection via message and email.

In both planned and emergency hospitalization, the insurer will directly pay the medical bills to the hospital and the insured may be required to pay the partial amount as per the terms and conditions of the policy. Please note that all expenses like expenses on consumables are not paid. In case, the company rejects the claim, then you don’t need to get worried. You can apply for reimbursement.

3 Points to Remember While Availing of a Cashless Health Insurance Claim

To understand the cashless claim, the insured need to remember three critical points:

1. A cashless claim can be availed only when you are admitted to a network hospital. Before getting admitted, you must check the list of hospitals that are in the panel of your insurer. You can visit the insurer’s website or call your insurer. You can also enquire about the same with the help desk of the hospital.
2. A policy document or medical card must be kept in a safe and secure place. The family members must also be aware of the place so that they can approach the insurance company at the time of any mishappening.
3. A cashless request needs to be made via an authorization form which is available at the insurance help desk of the hospital. You can also download it from the website of the insurance company or TPA.

Precautions for Cashless Health Insurance Claim

1. Please check previous prescriptions, especially previous medical history. Many times, the attending doctor makes certain remarks about the patient which may be only symptoms but the insurance company may consider it as pre-existing and reject the appeal for cashless. For example, Raghvan visited a doctor for chest pain. When the doctor asked, he admitted that he has this problem of chest pain for the last 3 years though he was not taking any medicine or treatment. But the doctor made a remark, “Known case of chest pain and cardiac problem for past three years”. Raghvan had a cardiac arrest and submitted the doctor’s report. The claim was rejected on the ground that cardiac problem was pre-existing because the policy was taken only two years ago.
2. Choose a network hospital and select a standard room or twin sharing room if the sum assured is not more than Rs. 5 lakh.
3. Ensure that hospitalization is necessary for taking treatment and not done for examination purposes. Ensure that the attending doctor is making a diagnosis and recommending hospitalization under a standard treatment protocol.
4. Under top-up schemes, you need to pay the deductible limit or show the certificate that the deductible limit has been paid by the insurance company.
5. Under the Copay system, pay your portion and sign the documents for cashless payment.

If you face any problem in availing of a cashless claim, then you can contact Insurance Samadhan. We have resolved 14500+ customer grievances related to insurance. If you want any guidance, then you can contact us. We’ll be happy to help you.

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

Cashless claim rejection

Mis-selling in a life insurance policy

Dengue Claim Rejection