Exhaustive Guide To Cashless Claims In Group Health Insurance

Cashless claim in health insurance is a benefit that allows policyholders to receive medical treatment without having to pay for it out of their own pocket. Instead, the insurance company pays the hospital directly, eliminating the need for the policyholderA person who pays a premium to an insurance company in exchange for the insurance protection provided by a policy to wait for reimbursement. This feature has become popular among policyholders, as it eliminates the stress and financial burden of paying for medical expenses.

What are the documents required for the cashless claim process in health insurance?

1. Health insurance policyThe legal document issued to the policyholder that outlines the conditions and terms of the insurance; also called the ‘policy documents / eCard: The policyholderA person who pays a premium to an insurance company in exchange for the insurance protection provided by a policy must provide a copy of their health insurance policyThe legal document issued to the policyholder that outlines the conditions and terms of the insurance; also called the ‘policy or eCard and any other relevant documents.
2. ID proof of the patient: The policyholderA person who pays a premium to an insurance company in exchange for the insurance protection provided by a policy must provide a valid ID proof such as a passport, driving license, PAN card or Aadhaar card.
3. Past treatment records like medical diagnosis or prescription papers (if any): The policyholderA person who pays a premium to an insurance company in exchange for the insurance protection provided by a policy must provide a copy of the medical diagnosis, which includes the doctor’s report, medical test results, and prescription.
4. Pre-authorization form: The policyholderA person who pays a premium to an insurance company in exchange for the insurance protection provided by a policy must fill out a pre-authorization form, which is provided by the insurance company, and submit it along with the above-mentioned documents.
5. Any other relevant documents supporting current diagnosis: Additional documents may be required depending on the policyThe legal document issued to the policyholder that outlines the conditions and terms of the insurance; also called the ‘policy and the nature of the claim.

How to navigate the cashless claim process with ease?

The steps to avail cashless insurance in a network hospital are:

1. Check Eligibility: Before seeking medical treatment, check if you are eligible for cashless insurance under your policyThe legal document issued to the policyholder that outlines the conditions and terms of the insurance; also called the ‘policy. Some insurance policies have restrictions on the type of treatments covered.
2. Choose a Network Hospital: Find a network hospital that provides the medical treatment you require. You can find a list of network hospitals on your insurance company’s website or by calling their customer service.
3. Inform the Insurance Company: Intimate your insurance company of your intention to avail cashless insurance. Provide details such as your policyThe legal document issued to the policyholder that outlines the conditions and terms of the insurance; also called the ‘policy number, the hospital you will be admitted to, and the type of treatment you require.
4. Provide Information to the Hospital: Once you have been admitted to the hospital, provide the hospital with your insurance policyThe legal document issued to the policyholder that outlines the conditions and terms of the insurance; also called the ‘policy details, including the policyThe legal document issued to the policyholder that outlines the conditions and terms of the insurance; also called the ‘policy number and the name of the insurance company.
5. Pre-Authorization: The hospital will then initiate a pre-authorization request to your insurance company. This is a process where the hospital provides details of your medical treatment and the estimated cost, and the insurance company confirms that the treatment is covered under your policyThe legal document issued to the policyholder that outlines the conditions and terms of the insurance; also called the ‘policy.
6. Approval or Denial of Claim: Based on the pre-authorization request, the insurance company will either approve or deny your claim. If the claim is approved, the hospital will proceed with your medical treatment. If the claim is denied, you may have to pay out-of-pocket and claim reimbursement from the insurance company later.
7. Discharge and Payment: Upon discharge, the hospital will directly bill the insurance company, and you will not have to pay anything out-of-pocket. In some cases, you may have to pay a portion of the medical bills, and the insurance company will cover the rest.

By following these steps, you can avail cashless insurance and receive medical treatment without having to worry about paying the medical bills at the time of treatment.

What are the reasons for deductions in a cashless claim?

It’s important to understand the terms and conditions of your insurance policyThe legal document issued to the policyholder that outlines the conditions and terms of the insurance; also called the ‘policy and the reasons for deductions, so that you can avoid any surprises or unexpected expenses when making a cashless claim. In a cashless health insurance claim, the insurance company may make deductions for various reasons, including:

1. Room Rent: The room rent may be limited to a certain amount per day under the policyThe legal document issued to the policyholder that outlines the conditions and terms of the insurance; also called the ‘policy, and any amount exceeding this limit may be deducted from the claim.
2. Co-Payment: Some insurance policies may require policyholders to pay a co-payment, which is a portion of the medical expenses. This amount will be deducted from the claim.
3. Non-medical Expenses: Expenses such as cosmetic products, telephone charges, laundry, food, etc. may not be covered under the insurance policyThe legal document issued to the policyholder that outlines the conditions and terms of the insurance; also called the ‘policy and will be deducted from the claim.
4. Pre-existing Conditions: If the medical treatment you received is related to a pre-existing condition, the insurance company may make deductions for this treatment.
5. Non-network Hospitals: If you receive medical treatment at a non-network hospital, the insurance company may make deductions for the expenses incurred.
6. Unauthorized Treatment: If the medical treatment you received was not authorized by the insurance company, the expenses incurred may be deducted from the claim.
7. ExclusionsSpecific conditions listed in an insurance or medical care policy that is not covered by benefit payments.  Common exclusions include: Certain treatments or procedures may be excluded from coverage under the insurance policyThe legal document issued to the policyholder that outlines the conditions and terms of the insurance; also called the ‘policy and will be deducted from the claim.

What is the difference between cashless and reimbursement claim?

Below is a concise comparison table that highlights the significant difference between the two primary types of health insurance claims: cashless and reimbursement.

Basis	Reimbursement claim	Cashless claim
Payment	You pay for the medical expenses and later claim reimbursement from the insurance company.	The insurance company pays the medical bills directly to the hospital
Process	You need to keep all the bills and receipts and submit a claim to the insurance company after discharge.	You need to inform the insurance company and the hospital before hospitalization, and the hospital sends a pre-authorization request to the insurance company.
Time	You need to pay the bills first and then wait for the insurance company to reimburse the expenses.	The cashless process is faster, as the hospital bills are settled directly by the insurance company.
Network Hospitals	Reimbursement process can be availed at any hospital subject to terms ( should not be blacklisted, should meet the minimum criteria for being called a hospital i.e. number of beds, ICU, trained staff etc)	The cashless process is only available at network hospitals of the insurance company.

In conclusion, cashless claims in health insurance can provide a convenient and stress-free way to pay for medical treatment. With a cashless claim, policyholders can receive medical treatment without having to worry about paying for it upfront, as the insurance company will pay the hospital directly. However, it’s important to understand the terms and conditions of your insurance policyThe legal document issued to the policyholder that outlines the conditions and terms of the insurance; also called the ‘policy, including the network hospitals, the reasons why a cashless claim may be rejected or subject to deductions, and the steps to file a cashless claim. 

By being informed and proactive, you can take advantage of the benefits of cashless claims under your health insurance policyThe legal document issued to the policyholder that outlines the conditions and terms of the insurance; also called the ‘policy and receive the medical treatment needed without financial stress.

In case you need any support, feel free to reach out to our expert team.

Please get in touch with us at any stage of your hospitalisation requirements. 

While our endeavour is to ensure that you are not inconvenienced on any count. At PlanCover.com, we represent your interests above all else. Our commitment and actions are aligned to ensuring that the process is smooth for you.