Do you know cashless claim process of health insurance policy?

Health Insurances 214 views

One of my friend Suresh Thakur took a health insurance policy from an XYZ company. Couple of years later, he suffered a chronic kidney failure and after few investigations got admitted to the hospital for the transplantation of the organ. The treatment cost worked out to be around Rs 1 lac. His family members thought that cashless claims will help them get the treatment done without paying anything from the pocket. But hardly were they aware of the fact that cashless claims can be made only in the network hospital of the insurance company. As he was admitted in the hospital outside the network of the insurance company, cashless claims could not come to the use. And his family members had to rely on the support from relatives and their savings for the treatment. But if you want to enjoy the benefit of cashless claim, then you must read the post carefully.

Cashless Claims

Cashless claim is a process by which your health insurer pays for the expenses incurred during the treatment at the hospital. Thus, it does not require you to pay anything from your pocket. But the treatment must happen at the network hospital of the insurer for you to receive the benefits of cashless claims. Also, you need to bear in mind that the treatment expenses are not above the sum assured. Expenses above the sum assured will have to be borne by you.

Types

Cashless Family Health Insurance

Cashless family health insurance policy allows you get the cover for your entire family.

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Cashless Health Insurance for Senior Citizen

This policy offers cover for hospitalization expenses, ambulance charges, as well as pre-existing conditions or diseases subject to the terms and conditions of the policy.

Operational Methodology

Health insurance firms collaborate with various hospitals after being satisfied with the quality of their healthcare services as well as the rates for different treatments. These hospitals are known as network hospitals, where you do not need to pay for the expenses incurred on the treatment. Instead, your insurer will get it done through Third Party Administrator (TPA), which acts as the linkage between the insurer and the hospital. Cashless hospitalization can be availed through two ways- planned hospitalization and emergency hospitalization.

Planned Hospitalization

If you know in advance that you are going to be admitted in the hospital in a few days, then it gives you the time to decide on the nearest network hospital. Here are a few things that you need to do while going through a planned cashless hospitalization.

  • Read the policy document of your health insurer to know the network hospital or get this information by calling to the toll-free number of the insurance company or checking it online.
  • Upon finalizing the network hospital, you need to bring your policy card to the hospital and ask for the pre-authorization form, which you can receive it at the insurance desk of the hospital. You can also download the form from the website of the TPA. Generally, the patient and the attending physician have to fill the first and second part of the form, respectively.
  • Then, you need to submit the form at the insurance desk, where the concerned person will scrutinize the details to check the authenticity.
  • Subsequently, the insurance desk will fax the form to the TPA for approval.
  • If the form gets approved by the TPA, then it will send an authorization letter showing the details of the sanctioned treatment amount.
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Emergency Hospitalization

This situation arises when you require immediate medical attention. You need to initiate cashless facility within 24 hours of hospitalization. Here are list of things that you are required to do while going for cashless claims during emergency hospitalization.

  • Show your health insurance card at the network hospital showing the details of your policy number, name of your insurer and the type of health insurance policy you have.
  • You are required to fill in the pre-authorization form.
  • Subsequently, the concerned individual at the insurance desk will accelerate your claim process by sending it to the TPA for approval.
  • After it gets approved, the TPA will process the claim within 6 hours.

What's Not Covered?

  • Fees of attendants/visitors
  • Service charges
  • Cost of oxygen mask, nebulizers, diapers, toiletries
  • Documentation charges

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