How Does Cashless Mediclaim Policy Work?
A health insurance company partners with various hospitals after checking their facilities, doctor's availability, quality of treatment offered. Such hospitals are known as ‘network hospitals’ of that particular insurer. If an insurance company claims to have 10000+ network hospitals across the country, it means you can get cashless treatment in all these hospitals.
How Do You Avail The Cashless Mediclaim Insurance Policy?
As said earlier, you need to first inform your insurer about your hospitalization. After reaching the hospital, you or your family members are required to fill a pre-authorization form. You can get the form either at the insurance desk of the hospital or on the website of your TPA (Third Party Administrator your insurance company has a tie-up with). The TPA will then decide to accept or reject your request for cashless treatment based on the terms and conditions mentioned in the policy wording.
Cashless Treatment Can Be Availed in Two Cases
1. Planned Hospitalization
In the case of planned treatment, you are generally aware that you will get hospitalized in a few days. You need to intimate the insurance company about your hospitalization before being hospitalized. On reaching the hospital, fill the pre-authorization form and submit it to the TPA. Your form will then be checked and verified by the TPA service provider. On approval, the insurance company facilitates cashless treatment to you by paying hospital bills and other expenses related to the treatment. This way, you can avail cashless treatment as per the terms and conditions mentioned in the policy.
2. Emergency Hospitalization
In case of an emergency, the pre-authorization form must be filed within 24 hours of hospitalization by one of your relatives. Your request will then be processed within 6 hours by the TPA. If it gets approved, you won't have to pay anything to the hospital. However, you can also choose to pay in cash and seek reimbursement later if you cannot wait.
In Which Case Is The Claim Rejected?
Almost all the health insurance plans offer a cashless mediclaim facility. But, there are some specific conditions when your health insurance provider may disapprove of your claim. The conditions may be pre-existing illnesses like HIV/AIDS, sleep disorders, sexually transmitted diseases, injuries caused due to self-harm, injuries arising during war or warlike incidents, etc.
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Health Insurance Cashless Mediclaim FAQs
How does a cashless mediclaim policy help me?
Cashless mediclaim helps you deal with medical emergencies by paying for your hospital bills. In a cashless mediclaim policy, all the medical bills are directly settled by the insurance company provided the amount falls within the sum insured limit. This leaves the insured tension free.
Can I avail of cashless treatment in any hospital?
Every insurance company has tie-ups with hospitals that are known as network hospitals. You can avail cashless treatment only at the network hospitals. If you are hospitalised in a non-network hospital, then you will be required to pay the hospital bill out of your own pocket and later file a reimbursement claim to the insurer.
In how many ways can cashless treatment be availed?
Cashless treatment can be availed in two ways: planned hospitalization and emergency hospitalization. In planned hospitalization, you need to inform the insurer about the hospitalization 24 hours in advance. In emergency hospitalization, you need to inform the insurer 24 hours after being hospitalized. The timing in both cases can vary from insurer to insurer.
It is advisable to read the policy wording to understand the cashless mediclaim facility in your policy. Or give us a call at our toll-free number 7551196989. Our experts will help you file a claim for cashless treatment as well as answer your questions related to health insurance.
Will I be required to pay anything at the hospital in spite of having a cashless mediclaim facility?
Yes. There are certain expenses that health insurance plans may not always cover you for. You are required to pay for these expenses from your own pocket even if you have a cashless mediclaim facility. These include the following:
- Expenses related to registration/admission
- Expenses related to attendant/visitor pass
- Special nursing charges that are not authorized by the attending doctor
- Service charges that are not a part of the room rent
- Charges related tor extra bed for attendant
- Bed retaining charges
- Charges for laundry, television, telephone, fax charges, etc.
- Cost related to toiletries, food, and beverages for attendants and visitors, etc.
- Expenses on medicines that are not related to the treatment
- Stationery, xerox or certifying expenses
Note that the list is only indicative and not exhaustive. Also, it may vary from insurer to insurer.
What happens if my cashless health insurance policy lapses during hospitalisation?
In case your cashless health insurance policy lapse during hospitalisation, but you were already hospitalised before the policy expiry date and had informed the insurer, then the insurer will honor the claims as per the terms and conditions of the policy.
If hospitalisation occurs after the policy lapses or during the grace period, then the insurer is not expected to admit the claim going by the prevailing rules. But it is best to inform the insurance company immediately on hospitalisation as the claim will be settled according to the circumstances of the case.
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