The increasing medical expenses have expanded the gap between healthcare costs and affordability. It is important to avail of health insurance plans as they help you during financial difficulties in the case of medical emergencies.
Lifestyle-related diseases are rising in modern society due to improper diet, inadequate sleep, and stress. The insurance coverage has also increased; however, many people still do not understand the claim process in case the need arises.
To avoid any last-minute hassles, it is recommended you understand the procedure and know the different methods to file health insurance claims.
Two Ways to File a Claim
Here are the two ways you may file a claim.
1. Cashless Claims
Under cashless claims, the insurer directly pays the bill to the hospital. However, cashless facilities are available only within the network hospital. A third-party administrator (TPA) works as the intermediary between you and the insurance company.
The hospital fills out the authorization form that comprises the estimated cost based on the initial findings. Once the application is approved, the entire cost is directly settled with the hospital, ensuring you do not have to pay any money out of your pocket.
2. Reimbursement Claims
If you do not avail of treatment from a healthcare institution under the insurer’s network, the cashless health insurance facility is unavailable. In this case, you need to settle the hospital bill and then submit it to the insurer to file a reimbursement claim.
To ensure your claim is accepted, you must provide all documents, such as the diagnosis, prescriptions, and discharge summary along with the bill. It is important to submit the documents at the earliest as most insurers will not accept claims after a pre-determined period from the date on which the costs were incurred.
Difference Between Cashless & Reimbursement Claim
Here is about cashless vs. reimbursement claims health insurance policies.
| Cashless claim | Reimbursement claim | |
| Hospital bill | Settled directly by the insurer | Settled by self before the claim |
| Type of hospital | At a network hospital | No limitation, the treatment may be availed at any facility |
| Time taken for settlement | Immediate settlement | Takes time |
| Documents required | No documents required | Hospital bills along with other documents must be submitted post-discharge |
Pros and Cons
| Cashless claim | Reimbursement claim |
| You do not need to pay any money from your resources | Initially, you need to incur all costs out of your pocket |
| A claim is settled immediately, without any delay | Once you submit all the documents, the insurer may take some time to reimburse costs |
| You need to avail of treatment only within network hospitals | No limitation on where the treatment may be undertaken from |
While cashless medical insurance appears to be a better alternative, there may be certain administrative issues. You do not have control over the TPA’s working; however, preparing in advance ensures there are no delays. It is recommended you start the authorization process in case of planned hospitalization.
Cashless Mediclaim is better as you do not have to worry about arranging the finances to meet the hospitalization expenses. Nonetheless, it is recommended you understand the procedure for both these claims to avoid any hassles in case the need arises.
What Should you do to Ensure Smooth Claim Settlement?
On the face of it, the cashless process looks very smooth, but it is marred with several administrative glitches. Even though you can’t control what happens at the TPA end, being prompt can make matters easier for you.
In case of a planned hospitalization, the process of getting the authorization approved can be initiated in advance. The authorization is valid for 15 days to a month, so it pays to start the process early. Store the TPA’s number and keep your family in the loop about it as it helps to get directly in touch with the TPA during emergencies.
Also Read: Top 10 Best Health Insurance Plans in India
When a Cashless Claim Can be Denied
As a policyholder, one should be aware that even a cashless facility can be denied in a network hospital. Such an incident may arise if the information sent by the hospital is insufficient if the ailment is not covered under the policy or if the request for pre-authorisation is not sent in time.
In a cashless situation, the hospital might not be able to give all the details required for the insurer to arrive at a decision. When an insured approaches a hospital with some symptoms, the treating doctor might not know the specific diagnosis and consequently the insurer might not be able to decide on the admissibility.
