Things you should know about Cashless Hospitalization

Rakesh Sinha, a financial consultant, was diagnosed with COVID-19 by the airport authorities when he landed in Bangalore. Traveling from his hometown Gujarat to work, he was held in a different city, away from his family, and also had to look out for suitable hospitals for treatment. Fortunately, he had a health insurance policy and immediately called the TPA hotline number to inquire about the list of network hospitals offering cashless treatment for COVID-19. He also logged onto google and searched using the term “cashless hospital near me” to find an appropriate hospital. Finally, the TPA support suggested a hospital, where he got admitted and got cashless admission. In a few weeks, Rakesh was fully recovered and returned to his home city without having to spend anything for his treatment.

After the COVID-19 pandemic, it has become clear that healthcare requires a lot of focus, and hospitalization becomes tough during times of distress. To address these issues, availing of a health insurance plan is the best available solution as it offers the facility of cashless hospitalization and reimbursement of treatment costs. However, if you don’t have health insurance or mediclaim and are looking to know about cashless hospitalization in India, you must know everything.

The claim process in a health insurance policy is of two types: Cashless claims and Reimbursement claims.

• Cashless claim: The cost of medical treatment the policyholder undergoes in any health insurance network hospital is paid directly by the insurance company to the hospital management.
• Reimbursement claims: The policyholder is reimbursed with the medical costs after the discharge from the hospital if the treatment was held in a non-network hospital. The costs of treatment are refunded back to the insurer, providing all the necessary documentation.

The cashless mediclaim facility is the most favored type of claim as all the expenses incurred by the policyholder, including treatment cost, hospitalization charges, surgery, medicines, OPD expenses, etc., are paid by the insurance company directly to the hospital. It saves time, money and provides peace of mind to the insurer, allowing them and their family to focus on treatment and recovery.

How to initiate cashless claims?

Not always, you can plan a hospitalization, but in some cases, if you are planning to get admitted to a hospital, the cashless hospitalization process is very simple. A detailed step-by-step guide on how to utilize the cashless health process is provided as follows:  

• Check if the hospital you intend to get admitted features in the network list provided by your insurer or TPA. For example, only if you get admitted to a cashless hospital will you be able to make use of cashless claims.
• Contact your insurer or a third-party administrator (TPA) and inform about hospitalization in advance, along with the diagnosis and name of the hospital.
• Also, do confirm if your insurer covers your ailment or illness under the list of illnesses allowing coverage.
• At the hospital’s insurance desk, fill in the authorization form, quoting your health plan details such as membership number ID or cashless card.
• Submit all the required documents related to your treatment along with the form that may include proofs, medical report, diagnosis, etc., for smooth processing of your cashless claim.
• The hospital shall then get in touch with your insurer to verify documents and proper approval, and the insurance company shall settle all the expenses bills.
• At the time of discharge, make sure to sign the necessary papers and collect the discharge summary along with other relevant documents in original from the hospital.

What documents are required for a cashless claim?

Opting for cashless insurance doesn’t require you to submit many documents, as the hospital will directly contact your TPA or health insurance company, which will take care of the necessities. But there are certain essential documents that you, as a policyholder, need to provide the hospital at the time of hospitalization as part of the cashless mediclaim policy procedure. They are:

• Signed claim pre-authorization form, available at the hospital
• KYC Documents (Aadhar Card, PAN Card, etc.)
• A prescription from a doctor recommending medical tests, hospitalization, and medicines.
• Original bills for pharmacy expenses, scans, treatment costs, etc., (if available)
• Original health insurance policy documents/ TPA cashless health card
• Diagnosis reports supporting your medical condition and hospitalization.

It is suggested you preserve a copy of the above-listed documents till the claim settlement process is completed in its entirety.

Ensuring your cashless claim is not rejected.

Although you may have submitted all the required documents, there are chances of it getting rejected for various reasons after a claim request is initiated. To avoid such situations and stay clear of any complications, here are few essential pointers that shall help you complete the claim and get it approved without any hassles.

• Make sure the hospital you intend to get admitted to features in the cashless hospital list provided by your insurer. Getting hospitalized in a non-network hospital will not allow cashless privileges and have to file reimbursement claims only.
• Understand the policy terms by reading through the document and know its features, inclusions, exclusions, waiting period, claim process, etc. If you initiate a claim against their terms, it will lead to rejection.
• File the claim request within 7 days of discharge from the hospital as some insurers reject claims received late.
• Research about the health insurance company before availing a plan from them by looking at their claim settlement ratio. A high CSR means the insurer has a soundtrack of settling claims on time, but a low CSR denotes a high claim rejection rate. Always choose a health plan from an insurer with a high claim settlement ratio.

Cashless hospitalization has many practical benefits, which are why health insurance companies are now promoting them to bring more customers into their fold. However, having read through the entire process of cashless claims from the above article, it is up to you to make sure you follow all the required guidelines and make yourself better equipped to avail the right health insurance policy.