Cashless Mediclaim Policy - How Does It Work?

While buying health insurance, we take care to select the best policy that sufficiently safeguards our family’s medical requirements. However, we often overlook the nuances involved with the conventional reimbursement process. How many times do you remember panicking in the middle of the night to the nearest ATM or calling a friend or relative to arrange cash for emergency hospitalisation? The mediclaim policy comes as a blessing in such difficult situations.

Reimbursement vs Cashless

Under the reimbursement policy, the policyholder is required to pay from his pocket the hospital bills, during and after the treatment at the time of discharge. After that, he has to submit the medical records, doctor’s reports, and bills related to the medical expenses with the TPA for the claim. Once approved, the insurer deposits the claim amount into his bank account. However, the failure to provide the necessary paperwork or complete formalities as per the insurance company requirement may lead to rejection of the claim. The claim might also be rejected if there is a slight mistake in the paperwork submission.

Under the cashless mediclaim process, you are not required to pay any hospital bills. Instead, you have to notify the insurer or the TPA that you would be availing medical treatment. You do not have to worry about the money for medical treatment. The cashless mediclaim policy covers your medical and hospitalisation needs. One thing to note is that health insurance companies provide cashless services only at network hospitals.

What is a network hospital?

The important aspect of the cashless mediclaim process is the network hospital. Every health insurance company has a list of network hospitals across the country where they provide cashless services. Health insurance companies tie-up with various hospitals after checking their rates and service quality. When the policyholder gets hospitalised in a network hospital, he does not have to settle the bill with the hospital. The insurance company or TPA directly settles the bill with the hospital. You can also get the information regarding the network hospitals of an insurance company from their official website. If the policyholder gets treated in a hospital, which is not listed under the network hospital, then he cannot avail cashless mediclaim for that round of treatment.

What is Third Party Administrator (TPA)?

TPA or Third Party Administrator acts as an intermediary between the insurance provider and the policyholder. TPA holds a license from IRDAI for processing of the claims and providing cashless facilities to the insurer. When you get hospitalised, you have to inform the TPA. TPA approves your request, coordinates with the hospital, and settles the hospital bill. You are provided with a health insurance card by the TPA.

What is a pre-authorization form?

Every hospital has an insurance desk, which addresses insurance-related issues. When you get hospitalised, you have to take a pre-authorization form from the insurance desk. Fill in all the required details related to the illness in the form, and the hospital’s representative fills the rest of the information. After completion, the form is sent to the TPA for claim approval. After due approval, the coverage is provided to the policyholder.

Steps involved in a cashless mediclaim process:

1. If a medical issue arises and there is a need to get hospitalised, check the list of network hospitals and select one.
2. At the hospital, go to the insurance desk and ask for a pre-authorization form. It can also be downloaded from TPA’s (Third Party Administrator) website.
3. Get the form filled and submit the form at the insurance desk of the hospital.
4. TPA will process the form and send the approval sanctioning the maximum treatment amount.

The benefit of cashless mediclaim is available for both planned and emergency hospitalisations.

Features of Cashless Health Insurance

Highlighted below are the features of cashless health insurance plans:

• Planned or Unplanned hospitalisation
• Pré-hospitalisation and Post-hospitalisation Expenses
• No Claim Bonus(NCB)
• Network Hospitals
• Emergency Hospitalisation
• Preventive health check-ups
• Ambulance Expense Coverage
• Daycare Expenses
• Domiciliary Treatment Coverage
• Critical Illness Coverage
• Free Look Period

What is Cashless Claim Settlement?

At the time when claims for the hospitalisation expenditure are settled by the insurance provider on your behalf and you are not required to pay anything, it is referred to as a cashless claim settlement.

Types of Cashless Health Insurance Policies in India

Broadly, there are three types of policies under cashless health insurance in India. They are:

• Cashless Family Floater Health Insurance

Under this type of Cashless health insurance policy, the proposer owns the insurance policy and the individuals covered under it are known as the members. An individual can get their entire family covered under a single family health insurance cover. All the beneficiaries of the health insurance policy can avail the benefits of cashless hospitalisation.

• Cashless Individual Health Insurance

Under the cashless individual health insurance plan, the individuals who have purchased the policy are offered all the benefits of cashless hospitalisation.
Cashless Senior Citizen Health Insurance
Under this type of health insurance plan, coverage and benefits to senior citizens is offered like ambulance expense, hospitalisation cost and much more depending upon the terms and conditions of the contract.

How Cashless Hospitalisation Works?

Health insurance providers network with various hospitals after verifying the quality of the healthcare services extended by them and also after working out the rates for various medical processes. These tie ups with different hospitals are also referred to as network hospitals, and when you undertake treatment in any of these network hospitals, you are not required to settle the bill with the hospital. The insurance company that is defined by TPA(Third Party Administrator) will synchronize and settle the bill with the hospital. There are two ways through which you can go for cashless hospitalisation:

Planned Hospitalisation:

When there is a planned hospitalisation, you have to complete the formalities 3-4 days before hospitalisation. Firstly, select a hospital in your neighbourhood from the list of network hospitals. Get the pre-authorization form and fill in the required information related to the illness history, etc. Provide the form at the insurance desk at the hospital at the time of admission. The person at the insurance desk will verify the information and fax it to TPA. The TPA will check the details and either reject or approve the request. If the request is approved, the hospitalisation expenses are covered by the insurer.

Emergency Hospitalisation:

There are often times where medical emergency crop up, as in an accident, injury, or critical illnesses. In such cases, the cashless mediclaim can be availed by informing the insurer or the TPA. You may show your health card at the hospital and fill in the pre-authorization form. The insurance desk will fast forward your request for the cashless process. Sometimes for emergency claims, there is an intimation deadline mentioned in the policy wording. Read the terms and conditions specified in the policy to enjoy the benefits of cashless mediclaim.

Benefits of cashless mediclaim:

1. The policyholder can avail emergency medical treatment without worrying about the funds.
2. No lengthy paperwork or documentation required. Thus, it is less cumbersome.
3. The treatment amount is directly paid to the hospital, and the process is hassle-free.
4. Since the claim amount is paid during hospitalisation, there is no waiting period.
5. Myriad of other advantages like transfer of policy, process validity outside India, and tax benefits.

Best Cashless Mediclaim Policies in India

There are several health insurance companies in the market that offer cashless mediclaim policies to the customers at affordable premiums. To make it easy for you to choose from them, here we present a list of some of the most popular health insurance plans offering the benefit of the cashless claims along with their features and benefits.

1. Max Bupa Health Companion

Anyone aged 91 days can be covered under the Health Companion policy offered by Max Bupa. The policy comes with sum insured options ranging between Rs. 2 lakh and Rs. 1 crore. The policy can be purchased on an individual or family floater basis. It offers several coverage features to the insured such as in-patient hospitalisation expenses, pre-hospitalisation and post-hospitalisation expenses, ambulance expenses, domiciliary hospitalisation expenses, etc. The best part is that there is no restriction on the maximum age limit to buy this policy.  

2. HDFC Ergo Optima Restore

People aged between 91 days and 65 years can be covered under HDFC Ergo Optima Restore policy for sum insured options starting from Rs. 3 lakh. The policy offers several benefits to the insured such as cover for domiciliary expenses, road ambulance expenses, in-patient hospitalisation expenses, daycare expenses, etc. Apart from this, the policy comes with 3 incredible benefits namely  Restore, Multiplier, and Stay Active. 

3. Max Bupa Heartbeat

The policy can be purchased by people aged at least 18 years for sum insured options starting from Rs. 1 lakh. The policy comes in three variants, each of which offer different coverage features. Some common coverage benefits under the policy include treatment taken outside India, maternity benefits, pre-hospitalisation and post-hospitalisation expenses, etc.

4. Reliance Health Gain

Reliance Health Gain policy is a comprehensive policy for families that people aged between 1 days and 65 days can be covered under. Available in two variants (plan A and plan B), the policy comes with sum insured options ranging between Rs. 3 lakh and Rs. 18 lakh. If covered under the policy, you can avail several coverage benefits such as daycare procedures, in-patient hospitalisation expenses, pre-hospitalisation and post-hospitalisation expenses, domestic ambulance expenses, etc. 

5. ICICI Lombard Complete Health Insurance

ICICI Lombard Complete Health Insurance policy covers people aged at least 3 months. The good news is that there is no restriction on the maximum age limit under the policy. Sum insured options start at Rs. 5 under the policy. It covers you for free health check-ups, in-patient hospitalisation expenses, pre-hospitalisation and post-hospitalisation expenses, etc. Apart from the in-built coverage features, you can also opt for add-on benefits such as maternity benefit, out-patient cover, newborn baby cover, hospital daily cash, convalescence benefit, etc. under this policy. 

Conclusion

Cashless mediclaim is really beneficial when you have limited cash reserve, and there is a need for medical treatment. The cashless mediclaim policy serves you with the best medical treatment without any financial stress. In the health insurance sector, you can find several insurers offering this benefit. Read the policy wording thoroughly to reap the best advantage of a hassle-free claim. 

Also Read

All You Need to Know About Cashless Claim Policy

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