Cashless health insurance

Table of Content

1. What Is Cashless Health Insurance?

2. How Does Cashless Health Insurance Policy Work?

3. Why Cashless Health Insurance is Important

4. Types of Cashless Health Insurance Plans

5. Benefits of Using Cashless Health Insurance

6. Things to Consider Before Buying Cashless Health Insurance

7. Documents Required for Cashless Hospitalization

8. Reasons Your Cashless Health Insurance Might Be Denied

9. Cashless Hospitalisation Claim Procedure

10. How to Use Cashless Hospitalisation

11. What’s Covered by Cashless Health Insurance?

12. What’s Not Covered by Cashless Health Insurance?

13. Common Reasons for Claim Rejection in Cashless Mediclaim

14. Cashless Claim vs. Reimbursement Claim: What’s the Difference?

15. Summary

16. FAQs on Cashless Health Insurance

What Is Cashless Health Insurance?

A cashless health insurance plan is one in which the insurer company pays for your medical expenses, such as hospitalisation charges, ambulance charges, etc., to the hospital directly. As its name suggests, it is a kind of claim procedure that you can choose instead of the reimbursement process, especially if you wish to preserve your financial liquidity by not paying the hospital bill yourself directly from your pocket. Through cashless claims, the insurer would pay and settle the bill directly with the hospital, without you needing to dig your pocket, provided you are eligible for the cashless claim benefits.

How Does Cashless Health Insurance Policy Work?

An initial payment is mandatory to commence treatment on hospitalisation. It can be stressful to arrange for finance in the absence of emergency funds. A cashless health insurance policy provides for timely treatment without any upfront payments. This is how cashless insurance works.

• Select Your Coverage Plan

Selecting the right cashless medical insurance is the initial step. Research policies that meet your requirements concerning coverage, premiums, benefits, and exclusions. The best cashless health insurance should offer extensive coverage of medical emergencies and hospitalisation expenses.

• Make Your Payment

The next step is premium payment to activate the plan. You should ensure regular premium payments to keep the plan in force for hassle-free claims process when there is a medical emergency.

• Find Network Hospitals

The benefit of cashless claims is available only at network hospitals. Ensure the hospitals listed under the plan are close to your residence.

• Show Your Insurance Card

The hospital places a pre-authorisation request with the insurance company to review the treatment required for the medical condition. For this, you will have to present your cashless health insurance card or health insurance policy details at the hospital’s insurance desk.

• Get Treatment

Upon receiving the approval, the hospital gives treatment without any upfront payment. The insurance provider pays the medical expenses incurred directly to the hospital.

• The Insurance Payout Agreement

The claim amount is established depending on the coverage limit. The policyholder has to bear the expenses not covered under the approved amount.

• Prioritise Recovery

With cashless health insurance, you can prioritise recovery without having to worry about arranging for finances.

Why Cashless Health Insurance is Important

Having a cashless health insurance policy can turn out to be beneficial in many ways, especially during medical emergencies wherein huge hospitalisation bills can financially disturb you by pushing you to make last-minute attempts to fund the big bill.

But with a cashless health insurance policy in place, you need not worry about all this, as the insurer will directly settle the bill with the hospital.

Here are some key benefits of buying a cashless health insurance for yourself and your family:

• Convenience

The biggest benefit of purchasing cashless medical insurance is the convenience that it offers to the policyholder. With the cashless facility, you do not have to worry about the big hospitalisation bill payments or reimbursements. The insurer settles the bill directly with the network hospital.

• Preferred Hospitals

Another benefit of purchasing health insurance with cashless coverage is that you gain access to any of your preferred hospitals, which can either be a network or a non-network hospital too as per your health condition, you can choose to get treated in any of your preferred hospitals, after factoring in its proximity to your residence, available faculty of doctors, infrastructure, etc. This prevents you from being forced to get treated at a particular hospital that falls into the network list of the insurer.

• Quality Health Care

Buying a cashless health insurance policy also opens the door for you to avail yourself of good quality healthcare without exhausting your precious savings. This ensures you do not compromise on your healthcare due to expensive medical treatment. The cashless feature of health insurance policies provides you with the facility to give your healthcare the highest priority without thinking about the cost.

• No Complicated Medical Billing

Last but not least, having a cashless hospitalisation and bill payment process saves you from the hassle of settling the big and complicated medical bills with the hospital. The tedious tasks, such as documentation, discharge formalities, bill settlement, etc, are taken care of by the insurer, as it directly coordinates with the hospital. This leaves you with more time to be stress-free and focus on recovery.

Types of Cashless Health Insurance Plans

Before buying a cashless health insurance plan, it’s important to understand the different types of policies available, that offer cashless coverage.

The following are the different types of cashless health insurance plans:

1. Cashless Coverage with Individual Health Insurance

This type of health insurance policy provides cashless coverage to one individual, i.e., a single policyholder.

2. Family Cashless Health Insurance

This type of health insurance policy provides cashless coverage to a whole family, including the policyholder, parents, spouse, and kids.

3. Health Insurance for Senior Citizens with Cashless Coverage

This type of health insurance policy provides cashless coverage for medical expenses of senior citizens, i.e., those who are aged 60 years and above.

4. Cashless Maternity Health Insurance

This type of health insurance policy offers cashless coverage for maternity and other pregnancy-related expenses for individuals who plan to have kids in the near future.

5. Group Health Insurance

Group health insurance plans cover a group of individuals. These plans are popular in companies and organisations wherein the employees are covered under the plan and get timely treatment during medical emergencies without financial stress.

6. Personal Accident Insurance

Life is uncertain, and you should be prepared to face the unexpected. Personal accident insurance provides financial security in the case of disability or death due to an accident.

Benefits of Using Cashless Health Insurance

The benefits of cashless health insurance are:

• Easier to Use

You can avoid the elaborate claim process involved in a reimbursement claim with cashless medical insurance. The hospital negotiates with the insurer directly and settles the bill.

• Instant Access to Medical Care

With cashless insurance, the policyholder gets access to immediate medical care even when he/she has no access to immediate funds. The hospital coordinates with the insurer to get approval for treatment coverage as permitted under the plan.

• Availability of Quality Treatment

The insured will have access to quality treatment without having to worry about arranging for funds. The patient is admitted immediately without going through the regular formalities, such as upfront payment.

• Minimal Documentation

There is no need to submit a huge list of documents for claim settlement, unlike reimbursement claims. The hospital coordinates with the insurer directly for approval of the medical expenses and settlement of bills.

• Approved Treatment in Advance

With cashless health insurance, you can get prior approval for treatment costs days before hospitalisation in the case of planned admissions. You will also have sufficient time to arrange for out-of-pocket expenses incurred for uncovered expenses.

• Peace of Mind

The policyholders can have peace of mind that they can get immediate treatment in case of medical emergencies, and they can depend on the insurer to settle the hospital bills.

• Easy Recovery

Managing finances to cover medical expenses can be stressful if you do not have emergency funds. If you have cashless insurance, you can focus on recovery without the hassle of arranging funds.

• Financial Stability

  Cashless health insurance provides financial security in times of medical emergencies. The insured need not worry about settling hospital bills as it is managed by the insurer.

Things to Consider Before Buying Cashless Health Insurance

Before you purchase a cashless health insurance policy, here are some crucial points to keep in mind:

• Cashless coverage and hospitalisation are generally available at network hospitals only.
• It is the hospital’s responsibility to adequately and timely provide a justification for the treatment the patient is undergoing.
• Keep in mind that a photocopy of all documents, including lab reports, medical bills, claim forms, discharge papers, etc, is required before leaving the hospital.
• Do not miss out on carefully reading all the minute details of the cashless health insurance policy, such as terms and conditions. Failing to do so can make you ineligible to avail cashless hospitality and other coverages when needed.
• If your claim amount exceeds the cashless sum insured, then you would likely have to pay the excess amount.
• Note that not all medical expenses are necessarily covered under cashless health insurance, so make sure you know which ones are covered and which aren't.

Documents Required for Cashless Hospitalization

When you are planning to opt for cashless coverage from your health insurance policy in India, do not miss out on this important list of documents that you would need to have in place.

1. Health Insurance Card or Policy Details:

If you have a health insurance card, then keep it handy. If not, then make sure to have a copy of your policy document so that you have access to details such as the policy number, assured sum amount, contact information of the insurer, etc.

2. ID Proof:

Another vital document you must have, is a valid government-issued ID proof, such as an Aadhar card, voter ID, passport, or driving license. These documents help the hospital do verification about your identity.

3. Doctor's Prescription:

Make sure you also have the doctor's prescription, which clearly mentions and recommends that you need hospitalisation.

4. Hospital Pre-Authorisation Form:

This crucial form is provided by the insurance company, which you need to fill out with the necessary details, and then get this form signed by your treating doctor.

5. Medical Reports and History:

If you have any previous medical records, lab reports, test results, or other treatment history which is relevant to your current treatment, then keep that handy too. This would help the hospital as well as the insurance provider to accurately understand your medical condition.

6. Hospital Admission Form:

Make sure you provide all the necessary information and medical details when filling out the hospital's admission form.

7. Claim Form:

You would need to fill out a claim form for your cashless health insurance. This form is generally available at the hospital, but it may also be available for download on your insurer's online website.

8. Emergency Contact Details:

Another vital piece of information that hospitals are likely to require is the list of your emergency contact numbers and also the names of family members or friends.

9. Cashless Health Card (if provided):

Some insurers prefer to issue a cashless health card to the policyholder. So, if you have such a card, it is better to carry it for smooth claim processing.

10. Any Other Specific Forms:

Depending on your hospital and insurance provider, there might be some more forms or documents that might be required. It is wise to check with both of them in advance and accordingly keep the required documents/forms handy.

Reasons Your Cashless Health Insurance Might Be Denied

It's true that having a cashless health insurance policy eases the financial burden of big hospitalisation expenses. However, there can be certain reasons due to which your cashless coverage claim can get rejected.

• Pre-existing Conditions:

Claims pertaining to pre-existing medical conditions can get rejected if you have not timely and honestly declared the information during the policy's application.

• Waiting Period:

Most health insurance policies have a particular waiting period, such as 2 years or 3 years, for certain conditions. If you file a claim for that condition during the waiting period, it's most likely to get rejected.

• Non-disclosure of Information:

If you try to hide any relevant health-related information or fail to provide accurate details about your history as well as present health, your claim is likely to be rejected.

• Policy Exclusions:

Many health insurance policies have a list of certain exclusions, such as cosmetic surgeries. Claims filed for such exclusions would be rejected.

• Incorrect Information:

Any kind of misinformation or errors found in your claim form can end up in rejection of your claim. Make sure to double-check each and every detail before filing the claim.

• Inadequate Justification for Treatment:

If you are unable to provide valid medical reasons and documents that indicate that the treatment or procedure for which you are filing a claim is necessary, then your claim can be rejected.

Cashless Hospitalisation Claim Procedure

The step-by-step cashless hospitalisation claim procedure is given below:

• Select a Network Hospital

The first thing to do is select a network hospital that is included in your cashless insurance plan. These hospitals collaborate with the insurance company and provide cashless service.

• Notify Your Insurance Provider

In the case of planned admissions, inform the insurance company 2 to 3 days in advance. Provide the policy details.

• Approval Process

The insurer reviews your request and communicates with the hospital for details regarding treatment requirements and expenses for pre-approval. The approval is based on the medical necessity and coverage available.

• Confirmation of Approval

Upon approval, the coverage details and the permitted expenses are confirmed to you.

• Admitting to the Hospital

Provide the pre-authorisation details at the selected network hospital’s billing desk to get admitted for the treatment.

• Care and Costs

The insurance company pays the approved amount to the hospital, sparing the policyholder the hassle of bill settlement during discharge.

• Finalising the Remaining Matters

If the actual expenses exceed the approved amount, the policyholder has to bear the differential amount.

• Final Insurance Settlement

You can claim reimbursement after discharge for any approved expenses not covered under the pre-authorisation by submitting the relevant documents to the insurance company.

How to Use Cashless Hospitalisation

There are two ways through which you can use a cashless hospitalisation facility:

Scheduled Hospitalisation

Knowing that you have to be hospitalised in the next few days ahead is known as planned hospitalisation. Here, you have to choose a network hospital with cashless capabilities. Should a planned hospitalisation be arranged, follow these rules to seek cashless hospitalisation:

• Use the toll-free number of the insurance company to learn about the nearby network hospital.
• Once you have chosen the one, take your policy card to the network hospital and ask for a pre-authorisation form.
• Either choose one from the insurance desk in the hospital or download this form from the insurer's website.
• Send your form to the insurance desk; their close inspection will ensure its authenticity.
• The form will then be faxed to the TPA for handling and either approved or denied.
• Insurer will write an authorisation letter detailing the authorised treatment sanction level should your pre-authorisation request be approved.

Urgent Hospitalisation

Regarding emergency hospitalisation, you should start the cashless mediclaim facility 24 hours before hospitalisation since you require immediate medical attention. Here is how one can use cashless hospitalisation:

• Show your health insurance card to the network hospital; it will include your policy number, insurance company name, and type of health policy you have.
• Complete the pre-authorisation form, and the individual working at the insurance desk will expedite your claim process.
• If you must wait for TPA approval, though, you can pay hospital bills and subsequently have them reimbursed by your insurance company.

Under emergency protocols, an insurer should handle an emergency hospitalisation claim ideally within a few hours.

What’s Covered by Cashless Health Insurance?

Keep in mind that all health insurance policies have a list of certain inclusions and exclusions. Claims filed for inclusions are likely to be accepted, whereas those filed for exclusions would be rejected.

Here's a list of what is generally covered under cashless health insurance:

Hospitalisation:

In case you need hospitalisation for your treatment, cashless health insurance can help cover the costs of medical tests, rooms, medicines, etc.

Doctor’s Fees:

A cashless health insurance policy also covers the fees of doctors who are treating you during your hospitalisation. You need to only focus on your recovery and not stress about the medical costs.

Surgeries:

Irrespective of whether it's a small or big surgery, your cashless health insurance will cover its expenses, thus ensuring that you receive the best quality of treatment without dipping into your savings.

Medicines:

All the costs of medicines prescribed by your doctor during hospitalisation are also covered under cashless health insurance.

Diagnostic Tests:

Whatever important tests are ordered by your doctor to help diagnose your illness would be covered under the policy. This is irrespective of how costly they may be.

Pre and Post-Hospitalisation:

Some of the cashless health insurance plans offer coverage of expenses related to your health both before and after hospitalisation, such as tests, consultations, medicines, etc.

Day Care Procedures:

Cashless health insurance policies also cover daycare procedures, even if you don’t require a stay at the hospital overnight.

Ambulance Costs:

If you require an ambulance to quickly reach the hospital, such expenses are often covered by cashless health insurance policies.

What’s Not Covered by Cashless Health Insurance?

Here's the list of what generally gets excluded and is not covered under cashless health insurance:

1. Pre-existing Conditions:

In case you previously had a health issue before you purchased the insurance, treatment for those issues might not be covered under cashless insurance immediately but might get covered after a waiting period.

2. Waiting Period:

For most policies, there is a waiting period at the beginning of the insurance plan, such as 1 year or 2 years, during which certain medical conditions do not get covered.

3. Non-Medical Expenses:

Your cashless health insurance usually covers medical expenses such as doctor consultations, surgeries, hospitalisation, and medicines. But when it comes to non-medical expenses like beauty treatments, cosmetic surgeries, etc., they are usually not covered.

4. Alternative Therapies:

Some health insurance policies may not cover alternative therapies or treatments such as acupuncture and naturopathy.

5. Regular Health Checks and Vaccines:

Regular check-ups, preventive treatments, vaccinations, etc. are also included. These are some of the expenses not covered under cashless insurance because they are considered routine check-ups which are carried out for health maintenance.

6. Pregnancy and Fertility Treatments:

Some of the basic health insurance policies might not cover the costs of pregnancy and fertility-related expenses and treatments, for which you might need a specific policy.

7. Mental Health:

Even though the importance of mental health is gaining prominence gradually, some cashless health insurance policies may still not fully cover mental health treatments or may have limited coverage.

8. Dental and Eye Treatments:

Many cashless health insurance policies do not cover expenses of routine dental check-ups, eyeglasses, braces, etc. unless you have included an add-on^* for such expenses in your plan.

9. Injuries from Hazardous Activities:

Policies may often not cover injuries resulting from hazardous activities or extreme sports.

10. Unproven or Experimental Treatments:

In case your treatment is considered either experimental or not widely acceptable, it might be excluded from your cashless insurance policy’s coverage.

Common Reasons for Claim Rejection in Cashless Mediclaim

Here are some of the common reasons due to which your cashless mediclaim may get rejected:

• In case you did not inform your insurance provider about the hospitalisation within the decided timeframe, such as 24 hours.
• If you availed treatment in a hospital that does not meet your policy’s requirements and guidelines.
• In case the treatment is not permissible under the cashless health insurance policy terms.
• If you provided incorrect information about a pre-existing disease and/or personal information at the time of buying the policy.
• In case the treatment is outside the cashless health insurance policy’s coverage, such as exclusions like cosmetic surgery.
• If the limit of the sum insured is already exhausted.

Cashless Claim vs. Reimbursement Claim: What’s the Difference?

Here’s a table to help you understand the difference between a cashless claim and a reimbursement claim:

Summary

Cashless health insurance makes you worry-free about paying hefty hospital bills, as the insurer settles claims directly with the hospital. You can stay stress-free and access medical services at your preferred hospitals without financial strain.

But why stop at health insurance? Life insurance is equally essential to secure your family's future in case of unforeseen events. While cashless health insurance covers medical expenses, a life insurance policy ensures your loved ones remain financially protected even in your absence. So, why not go cashless for health and secure your family's future with life insurance at the same time?

FAQs on Cashless Health Insurance

Q. Which health insurance is best for cashless treatment?

You can buy cashless health insurance from one of India’s biggest insurers, HDFC Life.

Q. Do Cashless health insurance plans cover OPD treatment?

Yes, many cashless health insurance policies do cover OPD treatment. However, it is wise to check with different insurers before buying any policy.

Q. My cashless claim got rejected. What could be the possible reasons for the same?

Your cashless claim can get rejected due to many reasons, such as insufficient documentation, incomplete information, waiting period violation, policy lapse, etc.

Q. What is the difference between cashless & reimbursement health insurance?

In the case of a cashless claim, the insurer directly pays the bill to the hospital. You, as a policyholder, either need to pay nothing or a very small portion. On the other hand, in the case of reimbursement health insurance, you, as a policyholder, have to pay the full amount to the hospital and then later get reimbursement from your insurance company.

Q. What are the types of cashless health insurance policies in India?

Different types of cashless health insurance plans are available in India, including Cashless Coverage with Individual Health Insurance, Family Cashless Health Insurance, Health Insurance for Senior citizens with Cashless Coverage, etc.

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