Cashless Treatment
We cannot always predict the future episodes of life but if we are alert we can surely prepare ourselves with whatever resources we have. Insurance is one such mode which helps us deal with future financial uncertainties better. It works as a protective layer in times of uncertainties. One such form of insurance cover is health insurance, which safeguards individual in times of medical emergencies.
Medical emergencies cannot be estimated and so at times, the cost of treatment, hospitalization and medicines could wipe off ones entire savings. With financial limitations one is also deprived of quality medical treatment. Health insurance works as a medium of relief to individuals since such a cover ensures proper medical helps in times of need. To be able to receive hassle free treatment, health insurance policies comprise of a benefit known as CASHLESS TREATMENT. This works as an added benefit to the medical cover.
How does Cashless Mediclaim Work?
Cashless treatment can be availed when the insured gets the treatment done from a medical centre or hospital which is listed on the insurance company’s empanelled list. Under this benefit, one does not need to settle the hospital bills with the hospital himself. The insurance company itself or sometimes represented by the TPA (Third party Administrators) covering the individual co-ordinates with the hospital and settles the bills.
The health insurance companies ties-up with the hospitals after negotiating the rates and medical support quality, such hospitals are called networked hospitals. Cashless facilities can be availed in these hospitals only.
The Third Party Administrators represent the insurance companies and are responsible for settling the claims both to be reimbursed and cashless. For an individual to be able to avail the cashless facility, the TPA is the final decision making authority.
Process of availing Cashless facility:
Pre Authorization Form: The insured is required to fill this form available either at the hospital’s help desk or the TPA website. Based on the detailed information filled in this form the TPA decides whether the insured is entitled to cashless claim.
Planned Hospitalization:
In case of planned hospitalization, individual is required to fill in the formalities 3-4 days before the hospitalization. The insured should take care of a few things before hospitalization:
- Insured should check the list of networked hospitals offered by the insurance company to select the most convenient one.
- Present the filled authorization form at the hospital as a part of communication to the TPA.
- The TPA on receiving the form either accepts or rejects the cashless claim and inform the individual and hospital along with the amount approved in case the claim is accepted.
Emergency Hospitalization:
In case of emergency hospitalization, the procedure to avail cashless treatment should be started within 24 hours from the time of hospitalization by producing the health insurance card. In this case, the procedure works on priority basis and so settlement does not take more than 6 hours.
What happens if the cost of treatment exceeds the approved sum?
The TPA approves only a part of the expenses incurred for the treatment. It is only when the complete bills along with discharge summary, all reports are received from the hospital, the TPA settles the entire amount.
Reasons for the claims to be rejected:
There could be cases when the claims could be rejected by the TPA. A few cases could be:
- The disease for which the insured is hospitalized is not cover by the insurance policy opted for.
- If the insured has exhausted the total sum assured approved for the policy year.
- The pre authorization form does not provide all required details.
Expenses not occurred under cashless facility:
There are a few non medical expenses which are not covered under the cashless facility:
- Registration, admission fee.
- Charges on the food.
- Ambulance charges.
- Documentation charges, service charges.
- Toiletries and medical support like nebulizers, oxygen masks etc.
Highlights of Cashless Facility:
- This facility is available only in case of networked hospitals.
- Individual is required to submit all medical documents along with discharge summary, total medical bill before discharge from the hospital.
- Cashless facility can be availed depending on the terms and conditions of the insurance company.
