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Home Articles Reimbursement or Cashless Claim in Health Insurance

Reimbursement or Cashless Claim in Health Insurance

IndianMoney.com Research Team | Updated On Thursday, August 22,2019, 06:17 PM

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Reimbursement or Cashless Claim in Health Insurance

 

 

If you have availed health insurance, you must know the claim settlement process in insurance firms. The insurer has 2 ways of claim settlement in a health insurance plan.

A) The cashless mode

B) The reimbursement mode.

Cashless claim:

The cashless claim is a facility where the insurance company directly settles your medical bills with the hospital. This facility is offered by the insurance company when you avail medical treatment at a preferred provider network (PPN). What is PPN? A PPN is a hospital that has a tie-up with the insurer also called a network hospital. Health insurance policyholders may avail the benefit of the cashless claim for both unscheduled and scheduled medical treatments.

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See Also: Health Insurance Benefits

Reimbursement or Cashless Claim in Health Insurance‚Äč

Cashless claim procedure

  1. In case of planned treatment, the policyholder has to collect a pre-authorization form, from the insurer and submit it with the requisite details. The approval has to be taken 4-7 days before the hospitalization.
  2. The documents and medical bills must be shared with the insurer, who will then assess the details of treatment as per the policy norms.
  3. The beneficiary has to submit the health insurance policy, the ID card issued by the insurer, pre-authorization and other required documents. The original medical bills must be submitted at the network hospital.
  4. In case of medical emergencies or unplanned treatment, the policyholder must contact the insurance company to collect the details related to empanelled hospitals. The hospital then connects with the insurer and the settlement is done.

Reimbursement claim

If you are admitted at a non-network hospital, you would have to make the reimbursement claim. Reimbursement claims are considered to be the conventional way of settling medical bills. Such claims are slow. In most cases, cashless claim facilities are used.

Reimbursement claim procedure

  1. The documents are evaluated by the insurer. They are then mapped against the policy cover.
  2. Along with the necessary documents, the original medical bills must be produced at the time of filing claims.
  3. After verifying the details and the documents, the health insurance provider reimburses the bills as per the policy terms.

See Also: Family Health Insurance Plan

Merits of cashless policies

Cashless health insurance policies cover inpatient care, pre and post-hospitalization expenses, domiciliary treatment, travelling expenses and other aspects. The premiums paid qualify for tax benefits under Section 80D of the IT Act, 1961. Claims are settled instantly.

Merits and demerits of reimbursement claims

To avail a cashless claim, the insured must be treated at a network hospital. The biggest benefit of reimbursement claims is that they enable customers to get treatment at preferred hospitals. Reimbursement claim is processed only after collecting the required documents and bills. Insurers delay payments when the documentation is improper.

FAQs

What is a third-party administrator?

A third-party administrator (TPA) is an intermediary between the insured and the insurer. TPA must be licensed by the IRDA.

What is network and non-network hospitalization?

When the policyholder gets hospitalized at a network hospital, it is called network hospitalization. On the other hand, if the policyholder gets hospitalized at a non-network hospital, it is called non-network hospitalization.

See Also: Exclusions of Health Insurance Policy

Will I be able to avail the cashless facility within 30 days of policy commencement?

Most Health insurance policies are offered after an initial waiting period of 30 days. The initial waiting period differs from insurer to insurer.

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IndianMoney.com Research Team

The research team at IndianMoney.com comprises of certified and experienced professionals who share the company's vision to make every Indian financially literate by equipping every Indian with right and unbiased advice. IndianMoney.com research team provides newsletters, articles, videos and FAQs on various financial products and concepts only to help you make wise financial decisions.

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