How To Avail Cashless Hospitalisation, Using Your Mediclaim?
Moneylife Digital Team 03 September 2020
Given the current COVID-19 pandemic and the news reports of the huge current hospitalisation costs, it is becoming even more important to have cashless mediclaim or health insurance. Cashless mediclaims have emerged as one of the key developments in health insurance over the past couple of decades as they have ushered in a smoother experience for the insured policyholder. 
 
Cashless health insurance enables insured patients to avail hospitalisation at select hospitals and get treated without settling the hospital bill. The expenses incurred during hospitalisation are directly paid by the health insurance provider or TPA (third-party administrator) to the hospital. All insurers have a list of TPA-empanelled hospitals or network hospitals and the insured policyholder can avail cashless hospitalisation at any of the TPA-empanelled hospitals / network hospitals of his/her choice. 
 
In cashless mediclaim, the patient does not have to pay at all (up to the limit mentioned in the policy) and, hence, does not have to arrange for short-term funds to meet hospital expenses or hospital deposit on an urgent basis. 
 
In traditional mediclaim policies, the insurer reimburses the insured patient after the treatment has ended and the patient has been discharged. Thus, in such conventional policies, the insured patient not only pays from his/ her pocket during the treatment, but there are chances that if they are not able to provide the necessary paperwork or complete the formalities as per the requirements of the insurer in time, the insurer may not even provide reimbursement. Hence, cashless mediclaim is always better than traditional (reimbursement-based) mediclaim policies. Hospitalisation is traumatic and, with cashless mediclaim, it can be made a little less harrowing for the patient and the family, since they do not have to run around to arrange for emergency funds.
 
Cashless mediclaim also provides tax benefits and can be renewed every year throughout the lifetime of the policyholder.
 
The insurer issues a health card (which is part of a kit comprising a guide book, policy details, what is covered, what is not covered and a list of network hospitals empanelled with the TPA) to the policyholder when he/she signs up for the health insurance. It is mandatory for the policyholder to carry this health card along with a valid photo ID for in case he/she needs to get admitted into any of the TPA-empanelled hospital. If the policyholder avails medical care in a facility that is not listed under the network of hospitals, they cannot avail of cashless mediclaim for that particular round of treatment.
 
This means that one can walk into any of the network hospitals across the country and get treated without having to pay one’s bills first and then claim expenses from the TPA. In case of any unforeseen accident, anyone on the spot can identify your health insurance company and your family can be informed. The health card carries a unique number which helps track the status of any claim by the TPA more quickly. 
 
How Does Cashless Mediclaim Access Work? 
Cashless hospitalisation can either be planned (in consultation with the doctor for an ongoing treatment) or unplanned (during any medical emergency or an accident). 
 
In case of planned hospitalisation 
1. Check if the hospital is on the empanelled list of network hospitals.
 
2. Submit pre-authorisation form along with relevant documents to your insurance provider, a few days prior to the hospitalisation. The pre-authorisation form is generally available with the network hospital/health insurance provider’s website/TPA offices. All the relevant details (policy no. /telephone no. /bank account no. /past history, etc) need to be filled and authenticated by the treating physician. 
 
3. Obtain the authorisation letter: The authorisation letter issued by the TPA, after scrutiny of the pre-authorisation request; will indicate the name of the insured/patient, the name of the hospital where treatment is required, the nature of illness / disease for which treatment is required and the monetary limit above which the insured / patient will have to pay. 
 
4. Submit this authorisation letter along with the identity card given by TPA to the admission counter in the hospital. 
 
5. Get treated: The insurer reviews the documents submitted by the hospital while you are being treated. These include: discharge summary, hospital bills, pharmacy bills, investigation reports, payment receipts and doctor's consultation papers. If required, the insurer might request you for a few more relevant documents.
 
6. Easy discharge: If approved, the claim is settled directly by the insurer/ TPA. You are only required to sign the relevant papers before getting discharged.
 
7. In case your claim is not approved, you can still complete your treatment. You need to clear the hospital dues and will need to apply for reimbursement claim. Remember to collect all your original documents from the hospital. In case the insurer raises a query, you would need to follow up with them and submit the relevant/additional documents required for processing the claim.
 
In case of unplanned hospitalisation or emergency hospitalisation
 
The process of unplanned hospitalisation is similar, except that in case of an unplanned or emergency hospitalisation, the requirement of prior intimation to the insurer is waived. Most emergency claims usually have an intimation deadline mentioned in the policy application documents. 
    
Nearly all cashless plans cover most medical conditions and emergencies but there are some temporary and permanent exclusions which the policy will never cover. They could be pre-existing illnesses, HIV/AIDS, routine medical check-ups (differs for various health insurance providers), dental procedures, experimental treatments, non-medical expenses or injuries caused by terrorist acts, wars or during illegal activities. However, most cashless mediclaim policies do cover other related expenses like ambulance charges, critical illnesses, pre- and post-hospitalisation medical expenses and in-patient care.
 
It is important to read the terms and conditions mentioned in the policy and provide the necessary documentation so that you can avail the maximum benefit of cashless mediclaim.
 
Comments
Dilip Modi
1 year ago
Thank you Money Life for the above article, useful to know all the necessary steps to avail cashless. May I please add a little comment concerning the issue of what should happen when the Medical insurance provider has been unable to renew its contract with the organisation that runs some of these Networked hospitals, especially during the current pandemic and there is no intimation given to policy holders about the change in status of the so called Networked hospital(s). A policy holder may have planned a contingency to be admitted to such an (near by) hospital only to find its is no longer cashless when arriving at its door step! Surely it should be incumbent on the insurer to alert all policy holders such events affecting choice of cashless hospitals. Not sure if IRDA has such circumstances covered in regulation?
Free Helpline
Legal Credit
Feedback