Cashless hospitalization is tailored to prevent these moments of fretting and panic when there is an emergency need for hospitalization, under which all the medical bills are paid directly by the insurance company, provided that the paid amount does not cover the sum assured for this health insurance policy. However, cashless mediclaim policy are applicable for those hospitals which are part of the network of the insurer. Cashless medical insurance is immensely beneficial to users, especially in situations when an ailing patient or his/her family may fail to get necessary funding prior to treatment. Alternatively, if he/she does not know many people in the city, this service will come to the rescue. There are several types of cashless health insurance in India across the following categories:
- Cashless family health insurance- This is the policy which is held under the name of the sponsor and those under it are known as members. The entire family can get coverage under this family health plan or policy.
- Cashless health insurance for senior citizen- This policy takes into account all hospitalization expenses, pre-existing ailments and charges for ambulances.
How Cashless Hospitalization Works?
The quality of medical facilities offered at various hospitals is ascertained by the insurance companies and rates for various treatments are also negotiated with these hospitals. Thereafter, there are tie-ups between insurance companies and these hospitals which become part of the network where your costs will be paid upfront whenever one gets admitted for medical treatments. The insurance company will have TPA (third party administrator) representation and the bill will be cleared accordingly.
Basically, there are two ways through which cashless hospitalization can be availed:
A) Planned Hospitalization- When you already know that you will be admitted to hospital in the near future and can choose your desired hospital accordingly.
Here is what you need to do-
- Go through the health insurance policy or talk to an expert on the toll free number provided for learning more about the network hospital nearest to you.
- Once you have decided on the hospital you want, you can get the policy card and seek the pre-authorization form which is available at the hospital’s insurance desk. You can download this from the TRA website as well. In most cases, the patient fills up the first portion while the other portion is filled up by the physician who is attending.
- The form should be given at the insurance desk where it will be carefully verified in order to ensure proper authenticity of the same.
- The form will then be faxed straight to the TPA for processing and this will be approved/rejected accordingly.
- Upon approval, the letter of authorization will be sent by the TPA which details the amount that has been sanctioned for costs of treatment.
B) Emergency Hospitalization- You will be requiring hospitalization immediately in such cases and hence there should be initiation of the cashless mediclaim provision within a period of 24 hours after being admitted.
Things you will need to do-
- The health insurance card should be displayed at the hospital and this should have the policy number, insurance company details and the nature of your policy.
- The pre-authorization form should be filled up and the claims procedure will be fast tracked thereafter. However, in case waiting for TPA approval is not viable, the bills may be paid by you and this can be reimbursed later on from the insurance provider.
- As per protocol, TPA, in case of emergencies, should process claims within a period of 6 hours.
You should keep in mind that there are a few expenses which do not have coverage in the cashless hospitalization scheme. These include the likes of ambulance charges, visitor/attendant fees, toiletries, expenditure on oxygen masks, nebulizer, diapers and other expenses along with charges for documentation.
The insurance company may choose to reject claims in particular situations, the reasons for which may be the following:
1. You do not have coverage for the illness for which you have got admitted in your policy.
2. You have already exhausted the entire allocation amount in a particular duration.
3. There has been a delay in notifying TPA about the hospitalization of the patient.