What to do when Cashless Insurance Claim is rejected

Often in our daily lives, we hear about the term “Cashless Insurance Claim”. Read along to know more about the Cashless Claim Process –

5 Simple ways to avoid Health Insurance Claim Rejection

1. In case of Planned Hospitalisation, the Policy holder needs to contact the Hospital prior to his/her admission and provides the pre-authorization request form to servicing TPA through the Hospital TPA Centre with complete policy details, ID Card and previous treatment record of the patient, if any.
2. In case of Emergency Hospitalization, the Policy Holder approaches the nearest Network Hospital and submits the servicing TPA Preauthorization request and policy related papers within 24-hours of admission in the Hospital.
3. Cashless can be extended in two portions – Initial approval at the time of admission which shall be between 50-60% of requested amount and balance at the time of discharge.
4. The Hospital may ask for the security deposit at the time of admission that would be adjusted at the time of discharge.
5. If Preauthorization is denied the Policy Holder pays the bill to the Hospital and files for Reimbursement with all Original receipts and medical treatment records with TPA.

When you are admitted to the hospital and apply for cashless claim, the hospital needs to submit all the required details to the insurer/TPA for them to arrive at a decision and approve. If, however, the hospital does not provide complete information as desired by the insurer/TPA, the cashless claim can be rejected.

Having a cashless claim while being admitted to the hospital is the main reason why we buy insurance. If we do not get this benefit, we feel cheated by the insurer. Let’s us understand how we can ensure our claim is not rejected. When in hospital we must check with the TPA desk designated in the hospital about the status of the approval. We must also check if there is any query on the case which needs to be responded and whether the same has been responded by the hospital or not. If you are in regular touch with your TPA desk and the treating doctor, you will be able to ensure that all queries are answered. Most cashless claim rejection happens due to some non-disclosure which now the company sees in the medical treatment and makes a requirement of previous treatment papers. The cashless is also rejected in non-network hospitals. You must always know the network hospital near your home in case of any emergency. The list is updated on the website and made available with the policy pack.

When the cashless claim is rejected, you need to apply for a reimbursement claim. You need to fill the reimbursement form and attach all original prescriptions, test reports, pharmacy bill and other miscellaneous bills. This is the most critical part and need to be submitted to the insurer/TPA office. Usually they about 30 days to pay the claim if everything is filed right. In case of any doubt or missing documents they raise an inquiry which the customer needs to respond.

We at Insurance Samadhan, help you file your reimbursement case correctly and in case any query is raised we help in resolving the same. We also represent the rejected cases to the grievance cell of the company, IRDA, Ombudsman and consumer court to help you get resolution to your genuine claim.

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