Know Major Differences between Cashless Claim Settlement and Reimbursement Claim Settlement Process

Medical emergencies can happen unexpectedly and may burn your savings utterly. Without a health insurance policy, it would be very difficult for you to manage your finances. A comprehensive health insurance policy will not only safeguard your family members but also lessens your financial burden. Many health insurance companies are welcoming their customers with health insurance plans that help policyholders get their claims at a medical emergency. A medical insurance claim is settled by two popular methods — cashless claim and the mediclaim reimbursement process. While purchasing a health insurance plan, you should have adequate knowledge of cashless claim settlement and the medical claim reimbursement process.

4 Major Difference between Cashless Claim Settlement vs Reimbursement Claim Settlement Process

Let’s look at the difference between the cashless health insurance process and the reimbursement process in health insurance.

• In the case of the cashless claim process, the insured policyholder doesn’t need to pay any medical expenses at the time of hospitalization. Because the insurer used to settle the bills directly with the hospital. But for the health insurance reimbursement process, a customer needs to bear all healthcare expenditures initially. Then, he/she can apply for reimbursement from the insurer after getting discharged from the hospital. Since the cashless mediclaim process reduces the financial burden of the policyholder, that’s why most people prefer it.
• For a cashless claim in a health insurance plan, the insured policyholder doesn’t need to collect and submit the hospital bills and other imperative documents like discharge summary. But on the other hand, a policyholder should collect all the bills and the discharge paper for the claim reimbursement process. If any document gets misplaced, the policyholder might face a claim rejection.
• Under the cashless claim process, most insurance companies offer their customers an array of hospitals where they can enjoy free treatment for their ailments. Because the companies will directly settle the bills with these hospitals. This means a policyholder can get treatment without paying if he/she selects a network hospital of the insurance company. But for the reimbursement model, a customer can choose any hospital for his/her treatment (in case of an emergency). Later, they can apply for claim reimbursement by submitting all the bills, discharge summary, and discharge paper.
• For a cashless settlement, your claim gets settled instantly. That’s why a cashless claim process is simple and convenient. But if you opt for a reimbursement claim process, it might take a long time because the policyholder needs to follow many procedures for reimbursement. Moreover, after submitting your documents, the insurance company will securitize your claim and reimburse it after satisfaction.
• The cashless claim process offers zero burdens to policyholders. A cashless claim model is ideal for those policyholders who can’t afford a humongous amount for their treatment within short notice. Thus, with the cashless claim, the insured policyholder and his/her family members can get admitted to a hospital without worrying about finances. But policyholders might get financial stress for a reimbursement claim because they need to pay the expenses initially, which might burn their pockets.

Procedure for Cashless Mediclaim

You can enjoy the benefits of the cashless claim only if you opt for a network hospital. According to the type of treatment, this can be divided into two (planned and unplanned).

a) The claim process for planned treatment at the cashless network:

For a planned treatment, you need to intimate your insurance company at least 4 days before your treatment date. Then, you need to submit a cashless claim request to the insurer at its relevant address through the post, e-mail, or fax. You can even contact the customer care desk of the insurance company for more details. After finishing all these steps, your insurance company will notify you and the hospital regarding the policy coverage and eligibility. You need to show your health insurance card from the policyholder and the confirmation letter at the time of admission.

b) The claim process for Emergency Treatment at the Cashless Network

In case of an emergency, you can get admitted to any nearest network hospital to avail of cashless claims by displaying your health insurance card. Now, the hospital will fill up the cashless claim form and submit it to the insurer through post, e-mail, or fax. The insurance company will issue the authorization letter mentioning the policy coverage. The insurer will pay your healthcare bills directly to the hospital. If the claim is declined, the insurer will issue a letter to you mentioning the cause of rejection.

Reimbursement claim process

The reimbursement claim process is applicable if you choose a hospital that is not impaneled with your insurance company. The insured policyholder needs to pay the medical bills and other costs related to hospitalization and treatment from his pocket. For claim reimbursement, the insured policyholder needs to submit all the required bills to the insurance company. The company will investigate the claim and will analyze the scope of the policy coverage. If the company is satisfied, then they will initiate the claim to the insured policyholder. If your treatment doesn’t come under the policy coverage, then the company will decline your claim.

The policyholder needs to submit the below-mentioned documents for claim reimbursement.

• Duly filled and signed claim form
• Doctor’s authorized medical certificate/form
• Discharge summary or card (original) from the hospital
• All bills and receipts (original)
• Prescriptions and receipts from pharmacies and the hospital
• The investigation report
• If it is an accidental case, then you need to submit the FIR or Medico Legal Certificate (MLC)

You must inform your insurer or TPA as early as possible because many Indian insurance companies want you to inform them within 30 days of expenses paid by you.

Now, you should have sufficient knowledge about the difference between cashless and reimbursement health insurance. A cashless claim is always a better option as it offers you a cashless facility at an impaneled hospital for your treatment.