Cashless Health Insurance: Meaning, Process, Benefits

The only reason why we buy health insurance is the financial assistance that it provides during the occurrence of any medical emergencies. And, after going through a stressful hospitalization, one thing that the insured expects is no hassle in hospital bills settlement and all the bills get settled directly between the insurance company and the networked hospital. 

Cashless insurance policy provides the advantage of immediate access to healthcare needs without worrying about the payment of hospital bills and treatment costs. Which is why, the majority of the insurance companies have started providing a large number of benefits on cashless mediclaim policies. 

Read ahead to find out the meaning of cashless health policy, how it works and how it benefits the policyholders in the hour of need.  

What Do You Mean By Cashless Health Insurance?

Simply put, under the cashless health insurance, all the medical bills are settled directly by the insurance provider and not the insured. The only condition here is, the total medical or hospitalization costs should not be more than the sum assured coverage and the hospital selected should be a network hospital. 

This kind of insurance is extremely beneficial in case of planned or sudden medical emergencies. As under cashless policy, the insurance company bears all the expenses related to hospitalization and treatment costs upfront and thus gives you more time to concentrate on other important matters such as making arrangements for the treatment or hospital admission formalities. 

Key Features of Cashless Health Insurance

• The medical expenditures are handled directly by the insurance company.
• To avail this facility, the patient has to be admitted in one of the network hospitals.
• Always keep a copy of all the required documents such as diagnostics reports, medical bills, discharge summary, and the claim form.
• The insurance company pays for the medical expenses, if it falls in the limit of sum insured coverage. Any amount which is excess of the sum insured, then the policyholder is required to pay the excess amount.
• Expenses beyond sub-limits predefined by the health insurance policy or items not covered under the policy have to be settled by the insured.

How Does Cashless Health Insurance Work?

Health insurance providers partner with different hospitals all over the country after examining their quality, reputation, rates and coverage of procedures. These are called networked hospitals, which have been vetted by the insurance companies after their thorough background check.

Cashless insurance is only available in these network hospitals. Thus, when you get admitted, you will always have the open option of getting yourself admitted in the networked hospitals to avail cashless facility. For this, there is an assigned TPA (third party administrator) who are  entirely responsible for coordinating with the hospital and settling your claims by the insurance company. This TPA is also in charge of approving or denying your cashless insurance claims.

However, the insured can also take treatment in a non-networked hospital. But, in this case, the policyholder has to settle the bills first and then seek reimbursement from the insurance company.

List of Top Insurance Companies Providing Cashless Health Insurance In India 

When Does A Cashless Health Insurance Claim Get Rejected?

The cashless claim in health insurance can be rejected for the following reasons: –

• If the patient is admitted to a non-network hospital which has no tie-up with the insurance company.
• If the pre-authorization claim request is not shared on time.
• If the medical condition for which cashless claim has been applied, is not covered or the waiting period is not over.
• The claim form or policy document contains incorrect information.
• If the policy has expired, any claims filed during this period will not be accepted.

Types of Cashless Health Insurance In India

Individual Cashless Insurance: The cashless insurance policy covers all the medical expenses of the key policyholder who can inturn avail the benefits of cashless hospitalization in the most hassle-free way. 

Family Cashless Insurance: This type of cashless insurance covers the whole family under a single premium policy. Here, the cashless benefits can be availed by all the insured family members including the main policyholder. As the coverage spreaded among all the members of the family, the sum insured is usually higher compared to the individual plan. 

Senior Citizen Health Insurance: This type of cashless policy provides cashless benefits to elderly people. The individuals covered under this policy receive cashless benefits for expenses such as ambulance costs, hospitalizations bills, and for much more coverage as per the policy.

Benefits of Cashless Health Insurance

Access to Speedy Treatment: When your cashless health policy is in place, it is very easy to get access to immediate treatment without worrying about the exorbitant hospital bills. You just have to notify the helpdesk at the hospital within 24 hours during an emergency and within 48 hours in the case of planned hospitalization.

Comprehensive Benefits: A cashless health policy is a very convenient way of utilizing the health insurance policy. One can also enjoy all the comprehensive benefits from settlement of medical bills to the full coverage of ambulance expenses and more.

Avail Coverage During Travel: Medical issues can arise while traveling also. But if you have your cashless insurance policy in place, you can easily avail treatment at any of the networked hospitals across the country.

Tax Savings: You can also avail tax benefits as the premiums paid for the cashless health insurance policy for family, individual, or senior citizens are exempted from tax under Section 80D of the Income Tax Act.

Factors To Consider Before Choosing A Cashless Health Insurance Policy

Network Hospital List: Before choosing a cashless health insurance policy, always check the list of networked hospitals that the insurance company has a tie-up with. The hospitals which are nearby your locality or in vicinity shall be included in the list, so that you can easily avail cashless treatment at the time of medical emergencies.

Sum Insured Coverage: The sum insured coverage of the cashless health insurance policy must be enough to cover you and your family at the time of medical emergencies. 

Co-payment and Other Sub-Limits: Always keep an eye on sub-limits and co-payment clauses. Co-payment is that percentage which the policyholder has to bear by the policyholder and not the insurance company. 

Waiting Period: Remember, any illness or treatment would be given cashless facility only when it does not fall under the waiting period. Pick the policy with the least waiting period. 

Daycare Procedures: Cashless policies also cover a large number of daycare procedures. Make sure to select the plan which has a huge number of daycare treatments. 

Cashless Claim Settlement Procedure

In order to avail medical treatment under cashless policy, one needs to fill the pre-authorization form which is available either with your TPA or at the hospital’s insurance desk. The filled-up form is then passed to the concerned TPA which further approves or disapproves the claim under these two circumstances:  

Planned Hospitalization: In a planned way of hospitalization, you need to notify the networked hospital within 48 hours of actual hospitalization. The process involved from filling up the claim form and to submit it to your TPA well on time. This will be further checked and vetted, so do not fill up any wrong information. Once approved, the claimed amount will be directly settled by the insurance company and hospital.

Emergency Or Sudden Hospitalization: In case of an emergency hospitalization in the networked hospital, the claim formalities have to be done within 24 hours of actual hospitalization. The whole process is fast-tracked once the pre-authorization form is filled up from the insured’s side. TPA, in such a situation, try to process the claim request within the same day also.

Inclusions and Exclusions of Cashless Health Insurance 

Inclusions:

• Pre-and post-Hospitalization expenses.
• In patient hospitalization costs such as daily room rent, doctor’s fee, intensive care unit (ICU) charges and more.
• Ambulance charges.
• Annual health check-ups.
• Day-care treatment.
• AYUSH treatment.

Exclusions: 

• Pre-existing diseases.
• Cosmetic surgery.
• Self-inflicted injuries. 
• Dental and hearing treatment.
• Illegal acts such as drugs and alcohol.