What is Cashless Mediclaim Policy – Working, Features & How to Claim
A cashless Mediclaim policy provides much-needed financial aid during medical emergencies. Policyholders, when faced with such a circumstance, can bear their hospitalisation expenses without any upfront payment. They can directly settle the bill with their insurer’s network hospital and receive the best quality treatment without any delay. A number of insurance companies in India offer such health insurance plans with a cashless claim settlement facility.
Here’s a detailed guide to cashless Mediclaim policy – how it works, its features and benefits, types, coverage, exclusions, tax benefits and more. Read on!
How does a Cashless Mediclaim Policy Work?
First, cashless Mediclaim policy providers check the efficiency, quality, rates, and expertise of various hospitals. Then, they choose the network hospitals and tie-up with them.
The tie-ups get renewed annually. So, if the insurance provider is unhappy with the services of a particular hospital, they might not renew the tie-up.
The facilities provided by the cashless Mediclaim policy will be available only at these network hospitals.
If you have a cashless Mediclaim policy, you need to get admitted to a network hospital. You need to inform the insurance provider as soon as you can and submit the required documents. The representative of the insurance company or a Third Party Administrator (TPA) will coordinate with the hospital and settle the claim between the hospital, insurance company and the policyholder.
However, if the policyholder is unable to furnish the required documents or if the claim is not aligned with the terms and conditions, it might get rejected.
Features and Benefits of a Cashless Mediclaim Policy
The salient features of these plans are decided by insurers and, therefore, vary among providers. That said, most cashless Mediclaim plans come with some standard features and have many associated benefits, such as the following:
- They allow one to avail of treatment at network hospitals without paying any cash.
- They include in-patient hospitalisation expenses for over 24 hours.
- Such plans cover pre and post-hospitalisation costs.
- Cashless Mediclaim policies comprise no claim bonus (NCB).
- They cover expenses related to ambulance, emergency hospitalisation, domiciliary treatment, etc.
- Such plans provide complementary health check-ups.
Reimbursement vs Cashless Claims
The table below illustrates the difference between reimbursement and cashless claims:
| Reimbursement Claims | Cashless Claims |
| One can avail reimbursement claims for medical expenses incurred at any hospital. | One can avail the cashless claim facility only at network hospitals. |
| Here, the policy-holder pays the bills and later submits the documents to the insurance company for getting reimbursed. | Here, the insurance provider pays the bills directly to the hospital. |
What is Covered under a Cashless Mediclaim Policy?
Given below are a few common inclusions under a cashless Mediclaim policy:
- Domiciliary hospitalisation expenses
- Pre and post-hospitalisation expenses
- Ambulance charges
- Daycare procedures
- Hospital room rent
- Inpatient hospitalisation
Types of Cashless Mediclaim Policy in India
There are several types of cashless Mediclaim policies, which can be broadly classified into these categories:
1. Individual Cashless Mediclaim Policy
This kind of plan financially covers only the policyholder against medical charges arising during hospitalisation.
2. Cashless Health Insurance Policy for Senior Citizens
This plan offers financial coverage against medical expenses to individuals aged 60 years or above.
3. Cashless Family Health Insurance Policy
Under this plan, one can cover himself/herself as well as the entire family.
How to Claim a Cashless Mediclaim Policy?
Insurance companies operate in collaboration with hospitals across India. As a result, they maintain a wide network of hospitals, wherein policyholders can receive treatment, and if eligible, avail of the associated benefits of a cashless claim process.
Typically, an insurer pays for medical expenses up to one’s sum insured directly to the hospital and in the following manner:
1. Emergency Hospitalisation
- In case you require immediate care, you are required to initiate the cashless insurance claim process within 24 hours of hospitalisation.
- Produce your health insurance card at the hospital. This card contains information like your policy number, the type of plan you hold, and the name of your insurer.
- Fill out the pre-authorisation form and submit it at the insurance desk.
- Your request is then processed and approved by a third-party administrator or TPA. Moreover, in emergency situations, it is compulsory for a TPA to process your claim within 6 hours of initiation.
- Your insurance company settles your medical expenses directly with the hospital.
2. Planned Hospitalisation
- Go through your insurer’s list of network hospitals and select one where you want to receive treatment.
- Submit your policy card to the hospital and collect the pre-authorisation form. Alternatively, you can download this form online from your TPA’s website.
- Fill up the form and submit it at the insurance desk.
- Wait for the TPA to process and approve your cashless insurance claim.
Usually, having a health insurance policy from a provider that follows a simple claim process allows the insured to access the required treatment without any delay. For example, Navi Health Insurance Policy follows an entire digital claim process, which facilitates cashless claim settlement in 20 minutes. This simplifies the cashless claim process significantly.
Tax Benefits under Cashless Mediclaim Policy
Section 80D of Income Tax Act enables a taxpayer to seek deductions against premiums paid for cashless Mediclaim policies for families, senior citizens and individuals.
A taxpayer can claim a maximum deduction of Rs.25,000 on the premium paid for his/her own self and family members, i.e. spouse and children. If the premium is paid for parents, then the taxpayer can claim an additional deduction of Rs.25,000.
If the parents are senior citizens, taxpayers can claim a deduction of Rs. 50,000 for paying health insurance premium. If the taxpayers are senior citizens, they can claim an additional tax deduction of Rs.25,000.
Also Read: Cashless Health Insurance Policy: Coverage Of Cashless Medical Insurance & Their Types
Steps to Choose the Best Cashless Mediclaim Policy
Given below are the steps that you can follow to choose the best cashless Mediclaim policy:
- Step 1: Analyse your requirements and choose the Mediclaim policy that is in line with them.
- Step 2: Examine the profile of the insurance provider carefully and go through the terms and conditions.
- Step 3: Check whether your nearest hospital is included in the list of network hospitals under the Mediclaim policy. See whether cashless facilities will be available. Moreover, check if the policy covers pre-existing illnesses or not.
Why Should You Buy a Cashless Mediclaim Policy?
Individuals turn to cashless health insurance plans for numerous reasons, some of which are discussed below:
1. Protection against emergencies
Medical emergencies, coupled with the rising cost of healthcare, can burn a hole in one’s pocket. So, it is necessary to plan for contingencies beforehand by purchasing a comprehensive health insurance policy.
Moreover, a cashless Mediclaim policy is all the more beneficial as it saves time, thereby streamlining the hospital admission process. An insured can avail of the required treatment by simply furnishing his/her health card to authorities.
2. Comprehensive coverage
Cashless health insurance plans usually account for multiple expenses, such as pre and post-hospitalisation charges, in-patient care, ambulance cost, and domiciliary treatment, among others. As a result, they offer comprehensive coverage to policyholders. In addition, some plans also cover diagnostic tests and health check-ups.
3. Safeguards one’s health during travels
Let’s say an individual faces a health emergency while travelling. Here, being in a new and unknown location can hinder him/her from availing of the best treatment. This is where health insurance policies with a cashless claim facility can come in handy. Insurance providers assure policyholders of reliable medical services that can be availed from any of their network hospitals. This reduces the hassle of arranging for hospitalisation and helps secure timely treatment in case of a medical emergency during travel.
4. Tax benefits
Holders of cashless Mediclaim can also enjoy tax benefits on the premium paid towards their plan under section 80D of the Income Tax Act, 1961. Premium payments up to Rs. 50,000 for individuals and Rs.25,000 for individuals aged below 60 years are eligible for tax benefits.
Also Read: 10 Best Cashless Health Insurance Plans: Benefits, Coverage & Claim Settlement Process
What Is Not Covered in a Cashless Mediclaim Policy?
Although cashless Mediclaim protects you from several financial blows arising out of hospitalisation, it comes with certain limitations. Therefore, certain health conditions are not claimable under these plans, including the ones listed below:
- Pre-existing diseases
- Diseases contracted within a specific predefined period from policy purchase
- Dental treatments
- Birth control and hormonal treatments
- Sexually transmitted diseases
- Non-medical charges, such as service charges, administrative fees, and expenses for toiletries.
- Vaccination
- Cosmetic and plastic surgery
- Maternity expenses (if not opted as an add-on benefit)
Factors to Consider Before Buying a Cashless Mediclaim Policy
Before purchasing a plan, we recommend that you pay heed to the following factors:
1. Sum Insured
The suitability of a plan’s sum insured depends on your location. For instance, if you reside in a smaller city, a sum insured of up to Rs.3 lakh should suffice. However, if you live in a metropolitan city, a sum of at least Rs.5 lakh will be essential.
2. Claim Settlement Ratio
This is one of the most critical factors to check before opting for an insurance company. Most leading insurers in India have a high claim settlement ratio. For example, Navi Insurance has a claim settlement ratio of 97% for cashless claims in India.
3. Maternity Benefits
It is imperative for individuals to check the waiting period before they can claim maternity expenses. Moreover, a plan with maternity benefits provides financial coverage to women against pregnancy-related expenses, thereby allowing them to tide over the same easily.
4. Day-Care Treatments
In today’s age and time, several treatments do not call for 24-hour hospitalisation. Therefore, some insurance companies that offer cashless Mediclaim cover such expenses under the heading ‘day-care treatment’.
5. Network Hospitals
One can make a cashless claim settlement at a network hospital of his/her insurer. Therefore, before buying a plan, you must assess your insurer’s list of network hospitals and ensure that it includes one in or around your vicinity.
Furthermore, you should keep the following points in mind:
- Cashless Mediclaim is only available at network hospitals
- If your cashless insurance claim request is denied, you can pay for all the expenses at the hospital, which will be reimbursed later.
- It is vital to promptly inform your insurer or TPA about your hospitalisation to avail cashless facility
- Cashless settlement is subject to the terms and conditions in the policy wordings of an insurance company
Final Word
Today, most insurance companies are lining up cashless Mediclaim plans. However, given the variety of plans available, it can be tough to choose a plan. So, we suggest you take the above-mentioned points into account and select an insurance policy that fulfils your requirements. Or, you can rely on notable names like Navi Health Insurance for comprehensive health coverage.
Navi has a wide range of 10,000 plus network hospitals and has premium options starting as low as INR 241 per month. If you are planning to buy health insurance, just download the Navi App now!
FAQs
Ans: You can make a claim as soon as the waiting period of your mediclaim plan is over.
Ans: A group medical policy provides coverage to the insured employees of an organisation or company for domiciliary care or hospitalisation during their policy period.
Ans: Policyholders can check their mediclaim status by visiting the official website of their insurance company.
Ans: A health insurance plan should cover at least 50% of your annual income. In addition, experts in personal finance recommend a minimum mediclaim of Rs. 5 lakh.
Ans: The entire time period that the insured person has to wait for, from the date of issuance of the insurance policy to avail of the benefits, is known as the waiting period. Different insurance companies have different terms and conditions with regard to the waiting period.
Ans: The list of network hospitals will be available on the official website of the insurance provider. It would also be clearly mentioned in the policy-related documents. It is advisable for people to go through the list of network hospitals carefully before purchasing the insurance plan.
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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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