Cashless Mediclaim Policy: Meaning, Types, How It Works, and More

All About Cashless Mediclaim Policy - BimaBandhu

We all face medical emergencies at some point in our lives for which prior planning is highly advisable. A common situation that arises to us all is the urgent need for cash (money) in case of emergency hospitalization. While buying a suitable mediclaim policy helps in dealing with such situations, you must also know about the cashless mediclaim policy. 

Let’s talk more about the benefits of buying the best cashless mediclaim policy for yourself and your family. 

What is Cashless Mediclaim Policy? 

A cashless mediclaim policy is a term used for most mediclaim plans offered by health insurance companies to provide cashless hospitalization facilities. At its core, it basically refers to the service with which you can avoid reimbursement formalities post treatment.  

Under a cashless mediclaim policy, all your medical bills will be settled to the hospital by the insurer directly (provided it falls within the chosen sum insured limit). The only condition to avail cashless facility under a mediclaim policy is that you must avail the treatment in a network hospital. It is highly beneficial in case of an emergency where the patient or his/her family members cannot make last-moment financial arrangements for the required treatment. 

How Does a Cashless Mediclaim Policy Work? 

Health insurance companies partner with renowned hospitals in different Indian cities after checking their service quality, medical procedures, and prices. They then call the partnered hospitals ‘network hospitals’ and create a list to be shared with the policy buyers. This networking process ensures that the insurers onboard the most credible healthcare institutions to form their network hospitals list.  

You can avail cashless mediclaim policy in these network hospitals without having to worry about making arrangements for cash. If you get hospitalised, a Third-Party Administrator (TPA) or an insurer’s representative will coordinate with you and the hospital to settle the claims post approval.  

What are the Features of a Cashless Mediclaim Policy? 

The salient features of these policies are decided by the insurance companies. In general, they all have the following features: 

  • No need to pay any money at the network hospitals 
  • Coverage for pre- and post-hospitalization expenses 
  • No Claim Bonus for every claim-free year 
  • Hospital daily cash if provided by the insurer 

What are the Benefits of Buying Cashless Mediclaim? 

  • Easy access to the best healthcare treatment for medical emergencies without financial worries 
  • Extensive insurance coverage based on the plan you select 
  • Tax benefits under Section 80D of the Income Tax Act, 1961 

How to Avail Cashless Mediclaim Policy Benefits? 

You can avail the insurance benefits under a cashless mediclaim policy in two ways: 

Planned Hospitalization 

In these cases, you already know that you will get hospitalized in the recent future and hence, can choose the right network hospital to avail the treatment. 

To avail of cashless hospitalization benefits, follow the steps given below: 

  • Read the list of network hospitals under your mediclaim policy or ask the insurer about a nearby hospital in their network. 
  • Take your policy card to the network hospital, fill a pre-authorization form, and then submit it to the insurance desk. 
  • Once the TPA approves or rejects your form, he/she will send an authorization letter that details out the sanctioned amount for your treatment. 
  • You can then proceed with getting the required treatment. 

Emergency Hospitalization 

In case you or your insured family members need immediate healthcare services, you must initiate the cashless mediclaim facility within 24 hours of hospitalization. Here’s how you should proceed in such situations: 

  • Visit a network hospital and show your health insurance card, which contains your policy number, insurer’s details, and the type of policy. 
  • Fill the pre-authorization form to expedite the claim process. If you cannot wait for TPA’s approval, you can choose to pay the bills out of pocket and then ask for reimbursement later from the insurer. 

As per the protocol, a TPA has to process the claim within six hours in emergency cases. 

Also Read: How Does a Mediclaim Policy Work? 

What are the Types of Cashless Mediclaim Policies in India? 

Different types of cashless mediclaim plans can be broadly classified into three categories: 

  • Cashless Family Health Insurance 
  • Cashless mediclaim for senior citizens 
  • Cashless mediclaim policy for individuals 

What is Not Covered in a Cashless Mediclaim Policy? 

The following expenses are generally not covered under cashless health insurance plans: 

  • Ambulance charges 
  • Service charges 
  • Toiletries 
  • Documentation charges 
  • Visitor/attendant fees 
  • Miscellaneous expenses for diapers, masks, etc. 
  • Treatment for pre-existing illnesses 
  • Injuries resulting from terrorist acts 

**The exclusions may vary from one policy to another. Hence, you must read the policy wordings to understand these terms clearly. 

What are the Top Reasons for Claim Rejection in Cashless Mediclaim? 

In many cases, the claims filed under cashless mediclaim policies get rejected. Given below are some of the most common reasons for the claim rejection: 

  • The illness for which a patient is hospitalized is not covered under the chosen insurance policy. 
  • The pre-authorization form submitted to the insurer does not have sufficient information to approve the claim. 
  • The entire sum insured has already been utilized. 
  • The patient or his family members have provided incomplete information about pre-existing ailments in the pre-authorization form. 
  • There has been a delay in intimating the TPA about hospitalization. 

**You must also know that TPAs cannot partially disallow or reject your claims. As per the Bombay High Court decision, only insurance companies can do that. This is because many TPAs were found rejecting the claim at the first stage to earn commissions/incentives from the insurers.  

Cashless Hospitalization at a Glance 

  • This benefit is only available at the network hospitals. 
  • It is the hospital’s responsibility to justify the treatment you need to the insurer. 
  • Keep a copy of all the documents, including lab reports, medical bills, claim form, and discharge papers with you for easy claim settlement. 
  • Read the terms – both inclusions and exclusions, of cashless mediclaim policies while buying one. 

You May Also Like to Read: All About Individual Health Insurance 

Cashless Mediclaim Policy FAQs 

Which is the best cashless mediclaim policy? 

The best policy for you is the one that you buy after researching and comparing various policies. Make sure you avoid buying any policy in a hurry without getting into the details. You can also use the cashless mediclaim policy premium calculator online to get an estimate. 

How do I get the cashless mediclaim? 

You can easily buy such policies online and then file a claim whenever required using the steps given above. 

What are the different types of cashless mediclaim process? 

There are two types of cashless mediclaim procedures in general – for planned hospitalization and emergency hospitalization. 

Which mediclaim is best for my family? 

There are many cashless mediclaim policies available in India. You can dig deeper into their specific details – features and benefits, to understand which cashless medical policy for family will be best. 

How much cashless mediclaim should I have? 

The sum insured you select under your cashless mediclaim policy should be based on your health condition, medical inflation rate, and your income. 

Get Adequate Information About Cashless Mediclaim at Insuropedia 

Finding the most suitable health insurance policy for yourself and your loved ones does require significant research. At Insuropedia, we are dedicated to making it easier to find all the required information about insurance policies in one place. In other words, you can rely on us to get all-inclusive information about cashless mediclaim.  

 

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