A dummy's guide to cashless health insurance

Now that cashless is once again the national buzzword, Harjot Singh Narula explains what you must know about cashless treatment under health insurance plan

Illustration: Dominic Xavier/Rediff.com

A medical emergency can hit you at any time and due to the skyrocketing cost of health care, a simple surgery can cost you more than Rs 2-3 lakh.

In such situations, arrangement of finances or cash is one of the biggest hassles which everybody faces. But a cashless health insurance policy can act as a saviour for you in such situations.

So let us understand the cashless treatment which is a life-saving benefit of health insurance by answering the following questions

What is cashless treatment?

A cashless hospitalisation allows you to undergo a medical treatment without paying anything from your own pocket, as the expense of treatment is directly settled by the insurance company subject to the limits under the policy.

The cashless facility is available with only the listed empanelled hospitals with your insurance company known as the network hospitals.

Insurance companies make tie-ups with hospitals after negotiating their rates and scrutinising their health care quality.

The cashless treatment can be availed by presenting valid documents for admission to the hospital.

Who are TPAs?

Third Party Administrators (TPAs) are the entities hired by the insurance companies for settling the claims both reimbursement claims as well as cashless claims of their policyholders.

The management of claims is outsourced by many insurance companies to TPAs for efficient claim management. TPAs play a major role in approving your request for cashless claim and provide their services.

What is a pre-authorisation claim form?

Pre-authorisation form is one of the prerequisites for getting the cashless hospitalisation facility initiated. It is a form which needs to be filled partly by the insured and partly by the attending medical practitioner.

The first half of the pre-authorisation form seeks details about insured/patient, family physician details, health insurance policy details, etc., which needs to be filled by the insured.

The second half of the pre-authorisation form seeks details from the treating doctor regarding the patient, relevant clinical findings, past history of ailments, proposed line of treatment, expected number of days in hospital, expected cost for the line of treatment, etc.

One can get the form at the insurance desk in the admitted network hospital or from the website of the TPA or insurer. The pre-authorisation form substantiates the basis for the cashless claim acceptance or rejection.

What is the process of cashless hospitalisation?

Cashless hospitalisation can either be planned hospitalisation or emergency hospitalisation. The following steps need to be followed to avail the cashless hospitalisation claim:

• Show your health insurance card specifying your policy details at the hospital insurance desk of the hospital
• Submit duly filled pre-authorisation form at the insurance desk of the hospital
• The person at the insurance desk will scrutinise the form and verify its completeness
• The pre-authorisation form is then faxed to the TPA or the insurance company (if they have an in-house claim settlement process)
• The TPA will then process the claim form and decide to either approve or reject the cashless hospitalisation request
• In the event, the request is approved by the TPA, it will send the authorisation letter with an approved amount for the treatment
• In case of planned hospitalisation it is advisable to take the approval from the insurer as soon as the doctor advises for hospitalisation for the treatment
• In case of emergency hospitalisation, there will be a fast track approval taken from the TPA or insurer to begin the treatment. In case of any delay regarding approval of cashless treatment, you might pay the bills and reimburse it post discharge from the hospital.
• Other essential documents required are photo ID proof, past illness records, complete medical reports, etc.

Once this is done the hospital will immediately start treatment and all your expenses up to the admissible limits will be processed by the insurance company in coordination with the third party administrator.

What can deny you cashless hospitalisation

• If the disease/ailment is not covered under the purview of the health insurance policy
• If it is a non-network hospital
• If the pre-authorisation form is incomplete or wrongly filled by the concerned
• If additional documents or information asked by the TPA is not provided
• If the sum insured under the health policy is exhausted for the policy year
• Non submission of any other required document or information for the process

What are the advantages of cashless health insurance policy?

The cashless health insurance policy will help you avoid the hassle of arranging cash on an immediate basis in case of medical emergencies. Some of the policies provide the cashless facility for treatment taken outside India, which is a great relief while you are abroad.

You get tax benefit under section 80D of Income Tax Act 1961. It is beneficial for people, who have no regular or limited income to afford expensive medical treatment.

What is not covered under cashless health insurance?

Through the cashless facility of a health insurance policy, you get cover for the policy inclusions subject to the policy terms and conditions. Expenses like ambulance charge, service charge, toiletries, documentation charges, diet charges, etc. may not be covered.

The lists of things which are not covered in the policy are clearly mentioned in the policy details. Your delay in intimating the TPA about hospitalisation may also lead to rejection of your claim.

Conclusion:

It is important to understand the terms and conditions pertaining to the cashless facility and the process to avail it, so that you can get maximum benefit from your policy. Also, remember to check the network hospitals located in your area which provide good health care services.

It will help you to avail cashless hospitalisation in case of medical exigencies. Do check the claim settlement process and the TPA involved with the insurer to sense the turn around time taken by the TPA for granting approval.

At times, delay at the end of TPA or improper coordination between the hospital and TPA may lead to rejection of the cashless claim. Don’t overlook other important policy benefits apart from cashless hospitalisation facility before buying the cashless health insurance policy.

Read the terms and conditions carefully before you make a final purchase.

Harjot Singh Narula is founder and CEO, ComparePolicy.com