Cashless Health Insurance Policy: Its Coverage, Types and Claim Process
Cashless insurance policies are healthcare plans under which the insurance provider directly settles the bill with the concerned hospital. This means that the policyholder does not need to pay any amount directly to the hospital for treatments undergone.
Most insurance companies have existing tie-ups with medical facilities, called network hospitals. Individuals need to seek treatment at any of these network facilities to avail cashless benefits against their claim. For instance, with the Navi Health Insurance plan, you can access cashless benefits across more than 10,000 network hospitals in India.
At the same time, they must make sure their medical procedure and cost are admissible, according to the policy’s terms and conditions. Accordingly, the insurer will arrange bill clearance post-treatment.
Cashless medical insurance schemes serve as viable alternatives to those policies wherein policyholders pay for treatments directly from their pockets. In such cases, insurance providers reimburse the expense incurred at a later date after the policyholder raises the claim.
Types of Cashless Health Insurance Policies
Before opting for a cashless medical insurance scheme, individuals must be aware of its different categories. They can opt for the one best suitable for their requirements accordingly.
Here are the scheme types available:
1. Cashless Family Floater Health Insurance
If you are looking for an insurance plan covering the requirements of all of your family members, opt for a family floater scheme. This way, all beneficiaries listed under this plan can avail cashless hospitalization and other benefits within the given coverage limit.
2. Cashless Individual Health Insurance
This can make for a more focused and high-coverage cashless mediclaim since it concerns only one person. You can also opt for an individual plan besides a floater plan for any family member with specific health concerns to enjoy an increased coverage limit.
3. Cashless Senior Citizen Health Insurance
Cashless senior citizen health insurance plan is specially curated for older individuals, who generally have a greater and periodic requirement of medical aid. Such plans exclusively cover pre-existing diseases, day-care expenses, and other costs besides hospitalization.
How to Make a Cashless Claim?
Here is a step-by-step guide on how to file a cashless medical claim once a requirement arises.
- Step 1: Choose from your insurance provider’s list of network hospitals.
- Step 2: Go to the hospital’s insurance desk to collect and fill up the pre-authorization form. You can also visit the official website of the Third Party Administrator (TPA) to download and take a printout of the document. Here, the TPA looks after the claim settlement process, as addressed in your insurance contract.
- Step 3: Inform the insurance company within 24 hours of hospitalisation in case of an emergency. If it is a planned hospitalization, inform 48 hours beforehand.
- Step 4: Submit the correctly filled-in and signed pre-authorization form to a representative of your insurance provider. Also, make sure to submit all required documents, including policy papers, ID proof, and doctor’s prescription, among others.
- Step 5: The TPA will then process and approve the claim for initiating cashless treatment.
Upon approval, the insurance company will sanction the maximum treatment cost to settle hospital bills post completion of treatment.
Benefits of Cashless Health Insurance Policy
While having a health insurance policy in place is crucial, a cashless one helps to enhance the benefits such as:
1. Immediate Treatment
A cashless health insurance policy is the best solution for emergencies. All you need to do is inform the policy provider at the earliest for speedy commencement of treatment. The whole process becomes highly convenient with immediate medical assistance.
2. Quality Treatment
Insurance companies perform several quality checks on medical institutions before including them in their network. Therefore, policyholders can rest assured about the quality of healthcare they can receive from these reputed hospitals. Additionally, policyholders can also consult trained healthcare experts free of cost to avail advanced assistance.
3. Relaxed Documentation
Individuals can enjoy a hassle-free claim process with cashless plans compared to the reimbursement process. You can apply via the Navi Health Insurance app to reduce paperwork while filing a cashless claim.
4. Covered Costs
As already mentioned, a cashless insurance plan covers a wide range of expenses. These include diagnosis, consultation fees, and medical expenses, among other treatment procedures. Therefore, individuals need not worry about ready cash availability.
5. No Need for Loans
Policyholders afraid of draining their savings also need not seek external funding for a medical emergency. All they need to do is pay a periodic premium to avail cashless benefits as and when required.
6. Tax Exemption
Individuals can also avail tax deductions on the insurance premium under Section 80D of the Income Tax Act.
Unique Features of Cashless Health Insurance
Illustrated below are the unique features of cashless health insurance policies:
- There is the provision of NCB – No Claim Bonus
- The benefit of hospital daily cash benefit
- Generally, it covers diagnostic test and one-time medical check-up
- No cash payment is required at any network-hospital
What is Covered Under Cashless Health Insurance?
All insurance policies come with certain exclusions. Cashless medical policy plans are no different. This is why it is important to keep a note of the expenses and treatments covered under your plan.
Here is a list of the standard inclusions:
- Expenses related to pre and post-hospitalization
- All costs incurred during overnight hospitalization
- Ambulance charges
- Day-care treatment, including chemotherapy and cataract operation, among others
- Alternate treatment under AYUSH
A more comprehensive plan may include other benefits like customised coverage, reduced waiting period, wellness rewards, and more.
With such benefits under cashless health insurance policies, you can effectively eliminate the need to arrange for cash should any medical emergency arise.
List of Items Not Covered under Cashless Health Insurance Policy
Generally cashless health insurance policies cover the following:
- Expenses for prescribed medicines
- Hospital expenses if the patient has to be hospitalised
- Expenses related to treatment
Given below is the list of expenses not covered by cashless health insurance policies:
- Service charges
- Cost of nebulizers, diapers, oxygen masks, etc.
- Documentation charges
- Toiletries expenses
- Cost of attendants
How does a Cashless Health Insurance Policy Work?
The insurance company directly pays the hospital when a cashless health insurance policy holder is admitted into an in-network hospital.
However, one should carefully check the list of the network hospitals that the insurance company covers.
Who Should Consider Buying Cashless Health Insurance Policy?
Cashless health policies are ideal if you fulfil any of the of the following criteria:
- If you are a senior citizen, then cashless health insurance policy can be an ideal policy because you don’t have to worry about cash payments.
- If you are the sole earning member in your family, opt for this mode of health insurance because you don’t have to worry about arranging cash in case a medical emergency occurs.
- If you are a self-employed individual, a cashless medical insurance policy can prove to be beneficial in the absence of a regular flow of cash.
- If you travel a lot, then cashless health policy will enable you to get treatment at a network-hospital if needed
- If you wish to avail of tax benefits, then Section 80C of ITA enables both people below 60 and senior citizens to avail tax benefits for cashless health policy premiums.
- If you belong to a nuclear family, you can consider a cashless health insurance option because it will save crucial time. You can concentrate on admitting your loved one to a hospital instead of arranging for the cash to meet hospitalization expenses.
Also read: Health Insurance Plans For Senior Citizens: How To Claim, Best Plans And Benefits
Different Ways of Availing Cashless Hospitalization
Given below are the different ways one can avail cashless hospitalisation:
1. Emergency Hospitalisation
If there is a medical emergency, then the cashless medical insurance policy holder will have to show the insurance card at the network hospital. This card contains your policy number, type of health policy and the name of the insurance company.
The pre-authorisation form has to be filled for availing the benefit of the insurance policy. An emergency hospitalisation claim is generally processed within 6 hours.
2. Planned Hospitalisation
Given below are the steps to avail cashless health insurance policy benefits for planned hospitalisation:
- Step 1: Contact the insurance company to know about the nearest network hospital
- Step 2: Next, visit the hospital with your cashless health insurance card and request for a pre-authorization form. One can also download this form from the website of the insurance provider
- Step 3: Then, after you fill up the form, it will be sent to TPA who will minutely go through it
- Step 4: Once the pre-authorization request for planned hospitalization is approved, the TPA will provide an authorization letter. It would provide all the details of the amount.
Differences between Cashless Claim and Reimbursement Claim
This table illustrates their difference:
| Cashless Health Insurance Policy | Reimbursement Claim |
| Insurance provider makes the payment directly to the hospital | The patient pays the bill and later gets it reimbursed from the Insurance provider |
| Applicable in network hospitals only | Applicable in any hospital across the country |
Also Read: Section 80DD Of The Income Tax Act: Terms And Conditions, Eligibility And Documents Required
Points to Consider before Buying Cashless Health Insurance Policy
Enumerated below are the points to consider before one buys a cashless health insurance policy:
- The facility is available only at network hospitals. So before zeroing in a cashless health insurance policy, check whether it covers hospitals near you.
- Check whether the policy covers medical check-ups and diagnostic tests or not.
- The sum insured should be based on your needs and salary. If you live in an urban area, the sum insured should be at least Rs. 5 lakh.
- Check whether it has a high claim settlement ratio or not. If it has a higher claim settlement ratio, better would be the process of availing the policy.
- Check the percentage amount of the claim that you have to bear as co-payment.
- Ensure that your chosen cashless health insurance policy provides the benefit of day care coverage which is treatment that will be completed in 24 hours.
- Check the waiting period of the cashless health insurance policy before one can avail maternity benefits. This will enable women to avail of the policy’s benefits in a hassle-free way.
- Read the terms minutely because there might be many conditions that make you ineligible to avail cashless health insurance benefits.
Reasons Why Claims Can be Rejected in Cashless Health Insurance Policy
Enumerated below are the important reasons why claim can get rejected in a cashless health insurance policy:
- Claim can get rejected if adequate information is not presented in the pre-authorization form.
- Claim rejection can get rejected if the policy does not cover the illness.
- If the patient has already used up the insured amount specified by his cashless health insurance policy, claim rejection will take place.
- Claim can also get rejected if the patient informs the insurance provider of the hospitalization after the specified time.
What does the Working of Cashless Hospitalization look like?
Cashless hospitalisation works in the following way:
- First, the health insurance providing company teams up with an array of hospitals across the country and forms a network of hospitals.
- Cashless health insurance policy holders can get admitted at any of the network hospitals to avail of the benefits of the policy.
- The medical expenses will be directly paid to the hospital by the insurance provider as per applicable terms and conditions.
Final Word
Now that you are aware of the claim process and benefits of cashless health insurance policies, you can easily apply for one and ensure that you are well-prepared during emergencies. Stay financially secure and avail the best of healthcare without eroding your savings. Make sure to go through all terms and conditions before opting for a policy.
FAQs
Ans. Yes, there are tax benefits associated with cashless health insurances. Section 80D of Income tax Act, 1961 enables people to avail these tax benefits. People aged below 60 years are eligible for a tax benefit upto Rs. 25,000 while senior citizens can avail tax benefit upto Rs. 50,000.
Ans. No. Cashless health insurance policy holders can avail of its benefits only at a hospital which is part of its network.
Ans. Yes, many cashless medical insurance policies cover pre-existing diseases. However it is subject to many terms and conditions. It is advisable to check them properly as conditions vary from one insurance provider to another.
Ans. The number of claims varies from one insurance provider to another. Irrespective of the number of claims, the sum of the insured amount will remain fixed. It is advisable that patients check the terms and conditions of the policy to see the number of claims that they are allowed.
Ans. Individuals can file a complaint to their concerned insurance provider in case they do not get their claim settled.
Ans. No, cashless plans generally do not include documentation and service charges. However, it depends on company policies, which may vary.
Ans. No, in case you are getting treatment from a non-network hospital, you need to clear the bill yourself first. Post payment, you can approach your insurance provider for reimbursement.
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Disclaimer: This article has been prepared on the basis of internal data, publicly available information and other sources believed to be reliable. The information contained in this article is for general purposes only and not a complete disclosure of every material fact. It should not be construed as investment advice to any party. The article does not warrant the completeness or accuracy of the information, and disclaims all liabilities, losses and damages arising out of the use of this information. Readers shall be fully liable/responsible for any decision taken on the basis of this article.
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