Compare & Buy Car, Bike and Health Insurance Online - InsuranceDekho
Claim, renew, manage & moreLogin
Hurry Up!
Save upto ₹75,000 on taxes in 80D. Buy a health insurance now!
View Plans

What Are The Problems With Cashless Mediclaim?

Updated On Jun 16, 2022

Though most plans offer cashless mediclaim and reimbursement claim settlement policy, reimbursement option is not favored because it involves the policyholders to pay the bills initially and then get it settled from the insurer. It is argued that a common man faces difficulty in meeting such expenses and so a cashless claim is better. However, a cashless mediclaim plan also has some challenges that make availing the claim a nightmare.

What Are The Problems With Cashless Mediclaim?

A cashless mediclaim insurance plan has two concepts; one is the Preferred Provider Network (PPN), which is a hospital that is tied-up with the insurer to provide cashless treatments to the policyholder. The other concept is that of a Third Party Administrator (TPA) that is the mediator between the mediclaim insurance company and the policyholder and is responsible for the smooth settlement of claims.

If a policyholder is admitted in a PPN hospital and identifies him with the TPA, he could avail of a cashless treatment and his hospital bills would be settled by the mediclaim insurance company directly without him having to shoulder the burden himself. This is the complete concept of a cashless hospitalization. However, this form of a claim settlement process is fraught with challenges and protocols.

Challenges Involved in Cashless Mediclaim Insurance

1. Getting a Part of the Claim Settled 

A very common scenario is where the mediclaim insurer settles only a part of the total expenses incurred. For instance, you might be hospitalized for appendicitis for which the insurer is paying about Rs.25, 000. However, you develop a complication post-surgery which results in an extended hospital stay chalking up a total bill of Rs.40, 000, out of which the mediclaim insurer pays only Rs.25, 000 as cashless claim and the pending amount is later reimbursed.

2. Not Getting the Facility of Cashless Treatment

This happens mostly in emergency cases where the TPAs require time to facilitate cashless mediclaim treatment. In such cases, the insured or his family is asked to bear the costs and later get them reimbursed from the insurer despite the insured being admitted in a network hospital

3. Excluded Treatments

It is an obvious one because treatments which are excluded from the scope of your health plan would not be provided by your mediclaim insurer.

4. The Document Jumble

Availability of cashless treatment requires adherence to documentation, especially the pre-authorization form which is to be submitted to the TPA to facilitate cashless treatment. Policyholders, being ignorant, fail to stick to the documentation, which results in difficulties in getting a cashless claim.

Conclusion

A cashless settlement, though convenient, has certain challenges when it comes to fulfilling the promise made. The challenges may stem from the fault of the policyholders, TPAs or hospitals. Passing the blame would be useless as the policyholder would be the one who ultimately suffers. You, as a policyholder, should take the precautionary measures to ensure adherence to protocols which would help you in getting a cashless settlement with ease and convenience.

Also Read: When Is It Appropriate To Buy A Health Insurance Policy?

What Is The Significance Of The Covid-19 Omicron Variant?

Disclaimer

This article is issued in the general public interest and meant for general information purposes only. Readers are advised not to rely on the contents of the article as conclusive in nature and should research further or consult an expert in this regard.

Health Insurance Coverage Calculator

Who do you want to insured ?

  • Individual
  • Couple
  • Family
  • Parents

Age of eldest insured member ?

Where do you live ?

Metro
Non-Metro
Disclaimer : Actual Coverage might vary basis your location, age and number of members

Best Health Insurance Plans In India

  • Cover 5 L
    Starting at 832/month*
    No room rent limit 100% no claim bonusUnlimited restoration benefits3 years PED waiting period
    View All Features
  • Cover 10 L
    Starting at 739/month*
    No room rent limit Unlimited restoration benefits50% no claim bonus4 Years PED Waiting period
    View All Features
  • Cover 5 L
    Starting at 447/month*
    No room rent limit 33% no claim bonus100% restoration benefits3 years PED waiting period
    View All Features
  • Cover 5 L
    Starting at 1,312/month*
    No room rent limit 50% no claim bonus100% restoration benefits3 yrs PED waiting period
    View All Features
  • Cover 5 L
    Starting at 448/month*
    Single Private A/C Room 20% no claim bonus100% restoration benefits1 year PED waiting period
    View All Features
  • Cover 5 L
    Starting at 664/month*
    No room rent limit 20% no claim bonus100% restoration benefits2 years PED waiting period
    View All Features
  • Cover 5 L
    Starting at 675/month*
    No room rent limit 50% no claim bonusUnlimited restoration benefits3 years PED waiting period
    View All Features
  • Cover 5 L
    Starting at 690/month*
    Single Private A/C Room 100% restoration benefits3 years PED waiting period
    View All Features
  • Cover 5 L
    Starting at 546/month*
    Twin sharing room Zero no claim bonus100% restoration benefits2 years PED waiting period
    View All Features
  • Cover 5 L
    Starting at 566/month*
    No room rent limit 20% no claim bonus100% restoration benefits3 years PED waiting period
    View All Features
  • Cover 5 L
    Starting at 1,770/month*
    Zero no claim bonusNo restoration benefits1 year PED waiting period
    View All Features
  • Cover 40 L
    Starting at 62/month*
  • Cover 2 L
    Starting at 146/month*
  • Cover 5 L
    Starting at 806/month*
    Single Private Room 10% no claim bonus100% restoration benefits2 years PED waiting period
    View All Features
  • Cover 5 L
    Starting at 476/month*
    60% no claim bonus150% restoration benefits4 years PED waiting period
    View All Features
  • Cover 5 L
    Starting at 526/month*
  • Cover 5 L
    Starting at 855/month*
    25% no claim bonus100% restoration benefits4 years PED waiting period
    View All Features
  • Cover 5 L
    Starting at 448/month*
    Single Private A/C Room 20% no claim bonus100% restoration benefits1 year PED waiting period
    View All Features
  • Cover 5 L
    Starting at 396/month*
    No room rent limit Room rent upto 2% of SI Room rent upto 1% of SI No room rent limit
    View All Features
  • Cover 5 L
    Starting at 738/month*
    No room rent limit 50% no claim bonus100% restoration benefits3 yrs PED waiting period
    View All Features
Note: Premium is shown for 18yr old individual of Delhi
Show More
Must BuyMust Buy

Why to Buy Health Insurance Policy Online from InsuranceDekho

  • Tax benefit upto 75,000*
  • Claim support everyday 10AM-7PM
  • 66 Lacs+ happy customers