What's inside? 🧐
- Introduction
- What is a cashless claim?
- How to file a cashless claim?
Introduction
Contracting a disease or undergoing medical treatment can be an arduous journey full of worries and uncertainty. From getting appointments with doctors to diagnostic tests, it already demands our utmost attention and energy. And if we have to arrange funds amidst all these physical and emotional challenges, it will add to the already heightened situation.
Wouldn’t it be great if you could focus solely on your recovery while someone else seamlessly takes care of your finances? This is exactly what cashless claims do for you. By choosing a cashless claim, you can concentrate on accessing high-quality healthcare and free yourself from relying on your savings. In this article, let us explore cashless claims and their detailed filing process.
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What Is A Cashless Claim?
A cashless claim is a process in which the insurer directly handles the expenses of treating an illness as per the policy’s terms and conditions. It comes into action when you seek medical treatment at a hospital that is part of your insurance provider's network. Basically, a network hospital refers to one that has a partnership agreement with the insurance company. Selecting a hospital from your insurer’s approved list of cashless hospitals eliminates the need for you to pay upfront. The insurer directly settles your medical bills with the network hospital, in this case, without you having to worry about it. You just need to pay for those expenses that are not covered by your policy.
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How To File A Cashless Claim?
Now, let us look at the detailed process of filing a cashless claim -
1️⃣ Check Eligibility For Filing A Claim
The first step to getting a cashless treatment is to assess whether or not you are eligible to make a cashless claim. This is particularly important for medical conditions that are typically covered after a waiting period of up to 3 years.
2️⃣ Check Cashless Availability
In most cases, it is preferred to receive treatment at a hospital that your doctor recommends, ensuring their availability throughout the process. Therefore, it is necessary to know whether or not your insurer provides cashless services at your desired hospital.
3️⃣ Check If The Hospital Is An Excluded Provider
If the insurer excludes the hospital you have selected, your claim will not be eligible for cashless payment. And you will have to arrange for funds to cover the expenses upfront before the insurer provides reimbursement as per the terms and conditions of the policy. Conversely, if your chosen hospital is not listed as an excluded provider, it is advisable to confirm with the hospital whether they accept cashless payments from your insurance provider.
4️⃣ Know Your Policy’s Limits & Conditions
It is essential to be well-informed about the limitations and conditions of your policy and fully comprehend its scope of coverage. So, review your policy for any financial restrictions, such as a cap on room rent, ICU charges, sub-limits on certain diseases and treatments, especially for planned procedures, etc.
Moreover, it is important to ascertain whether your policy includes coverage for non-consumable items. If it does, check whether there is any specific list of items that is excluded from coverage. By doing so, you can better understand any potential out-of-pocket expenses you may need to bear.
5️⃣ Keep The Necessary Documents Ready
Here’s a list of the documents you will need to make a cashless claim -
- Your policy copy or cashless card
- All your relevant medical records that have led to the hospitalisation, including initial consultation documents and subsequent follow-ups, for any medication or medical condition, whether directly or indirectly related to the current ailment.
- KYC of the proposer (PAN card, Aadhar card, Passport-size Photo)
- ID proof of the patient
- Police FIR (in case of accidents)
Failing to provide the necessary documents can lead to the denial of your cashless claim. In such a situation, you will have to pay the medical bills upfront and seek reimbursement later. To avoid any complications in the claim process, it is essential to ensure that you have all the necessary documents readily available.
6️⃣ Notify The Hospital
In case of planned hospitalisation, you need to submit a claim request at least 3 to 4 days before your admission. And, for urgent hospitalisation, you need to submit the claim request within 24 hours of your admission. The hospital will ask for specific details and documents to initiate a pre-authorization request with your insurance provider for cashless claim approval.
Here’s a list of the details and documents you will need to provide -
- Health card issued by the insurer
- KYC documents of the proposer (PAN card, Aadhar Card, Passport-size Photo)
- ID proof of the proof
- KYC documents of the insured person
- Policy Number
- Name of the policyholder
- Name & address of the insured for whom you are filing the claim
- Type of the illness/injury and the required treatment/surgery
- Name and address of the medical practitioner who is attending to the patient
- Proposed date of admission
- Comprehensive medical history, including past medical records related and unrelated to the present ailment. In case this is different from the disclosure made during policy inception, you can possibly face a claim rejection.
Ensure you retain copies of all original documents you submit for future reference and documentation purposes.
7️⃣ Be Ready To Pay An advance Deposit
It is important to note that while your insurance company’s call centre may operate 24/7, the insurance desk at the hospital typically operates until 7 pm on regular days and remains closed on Sundays. As a result, the pre-authorization process may take 6 to 24 hours, depending on the insurance company. The insurance desk may also raise queries during this process, which you will need to respond to promptly.
During this period, the hospital may request an advance deposit, which will be reimbursed at a later stage. To avoid any financial strain, it will be beneficial to maintain an emergency fund specifically for such advance payments.
Please note that any medical expenses incurred before hospitalisation will need to be claimed separately from your insurer. Therefore, it is crucial to securely store all original prescriptions, bills, receipts, and reports (including films) related to your hospitalisation.
8️⃣ Follow Up On The Claim Process
Once your treatment is completed and the discharge date is determined, the hospital's insurance desk will notify your insurer and submit all the necessary paperwork, including the final bill and discharge summary. Following this, your insurer may provide updates on the progress of your claim through your registered mobile number or email.
However, sometimes, the hospital may fail to inform the insurer about your discharge or overlook sending the required documents. This can result in a potential delay in the approval process. Thus, it is essential to stay informed about the status of your claim by regularly checking for communication from your insurer or seeking guidance from your financial advisor.
Typically, the approval process takes around 2 to 6 hours after your insurer has been notified of your discharge. During this time, your insurer may raise queries that require prompt responses. Therefore, to speed up the settlement of your claim, it is essential to diligently follow up either with your advisor or directly with your insurer.
If the final approval does not arrive or is delayed, you might have to wait at the hospital or make upfront payments that will be reimbursed later. Thus, it is essential to remain prepared for such situations and have the necessary financial backup.
9️⃣ Examine The Final Bill And The Approval Letter
Once you receive your final bill and approval letter, it is crucial to thoroughly review them to understand which expenses have been approved and which have not. If you have any doubts or confusion, do not hesitate to contact your insurer or advisor for clarification and guidance.
The approval letter may explicitly state certain expenses as 'do not collect from the patient.' It is important to carefully check and ensure that you do not make any payments for those expenses. However, there may still be other unapproved expenses for which you will be responsible for paying before getting discharged from the hospital.
Additionally, hospitals may retain a certain amount as a deposit beyond the discharge date until they receive their payout from the insurance company. It is crucial to keep the receipt for this deposit as it will serve as evidence while collecting the refund later.
Suppose your claim has been reduced due to a shortage of available sum insured, policy limits, exclusions, or co-pays. If you have another health insurance policy, you might be eligible to claim the remaining amount through reimbursement from it. It is important to remember that every cashless claim typically includes a reimbursement component for pre-hospitalisation and post-hospitalisation expenses. So, ensure that you file a claim for such expenses.
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