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All That You Need To Know About Cashless Health Insurance Claims Procedure

By Author: Easy policy
Total Articles: 20

The cost of hospitalization has magnified over the last few years. It is not within the financial scope of most insured to pay for the cost of hospitalization from their savings and in such cases cashless hospitalization becomes important.

Here, we discuss some important facts regarding cashless hospitalization, which you must be aware of.

Cashless claim is available only in the network of hospitals pre-approved by the insurance provider

The most important pre-requisite for you to get cashless claim is that you should take your treatment in a hospital that is pre-approved by the insurance service provider in their network. The hospitalization may be planned or you may take it for an emergency situation like an accident or a stroke.

Planned Hospitalization

For a cashless claim, if it is a planned hospitalization, you would have to inform the hospital in advance about your insurance plan. You can give advance intimation of 3-4 daysto the hospital for the formalities. The hospital would fill a pre-authorization form, which will carry details of your policy and the approximate cost of treating your illness, which will be submitted to the Third Party Administrator (TPA) for authorization. The TPA will check the policy terms and accordingly grant the permission or reject the form. The TPA will inform about its decision to the hospital via a fax.

Emergency Hospitalization

A lot of hospitalizations arise out of emergency and in such a scenario you can demand a cashless claim, which has to be submitted to the hospital within 24 hours of admission. No doubt it is a panicky situation, but one of the relatives can come forward to managing the formalities for a cashless claim. The health insurance card can be submitted to the hospital and they will take care of the approval process. The hospital will fast track the TPA approval process. In an emergency situation, the TPA is required to process the claim within 6 hours of receiving the pre-authorization form. If it is not advisable to wait, you always have the option of taking the treatment and then filing for reimbursement of the expenses incurred.

What if the TPA rejects your claim?

A TPA generally rejects the claim in following situations:

You have already exhausted your sum assured limits

The illness for which you may be seeking treatment is not covered under the policy terms

If you think the TPA has wrongly rejected your claim, you can still proceed with filing a claim for reimbursement of your expenses. In order to avoid such a situation, it is advisable to read the policy carefully when you receive it. All health insurance policy document explicitly state health conditions which are not covered by the policy.


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