Know-how of Health Cashless and Reimbursement Process

The moment for truth for any customer who has bought an insurance policy is at the time of filing an insurance claim.

With respect to a Health Insurance policy, such a scenario of the Claim Process arises at the time of hospital admission for Cashless admission or while filing a reimbursement claim for medical expenses incurred as a non-networked hospital.

In India, General and Health insurance companies are tied-up with hospitals across country to offer Cashless feature to their customers for any untoward medical emergencies.

Every customer of an insurance company is provided with a Cashless Health card from the insurance company, that has the customer details and Policy number mentioned on the card.

The health card also provides an emergency and toll-free numbers for quick reference for the customer to get in touch with the insurance company at the time of admission.

Particular steps need to be followed up by the insured at the time of availing cashless hospital treatment in Network Hospitals.

First & foremost the insured needs to intimate the Insurance Company usually within 48 hrs of admission.

Nowadays, insurance companies & TPA’s provide online portals for intimating the claim & further help the customers to track claims on a real-time basis. 

The Authorization team at Insurance Company/TPA on receipt of preauthorization form from hospital verifies it with terms & conditions of the policy opted by the insured & provide the initial approval.

Further enhancement approvals may be issued on request of the hospital, subject to terms and conditions of the policy & post justification from the treating doctor for a prolonged stay, use of medicines, extra investigations needed, specialist consultations required etc.

Cashless Claim Process

The claims team may even decline the request if the treatment falls beyond the coverage of the policy. At such time, Insurance Company and hospital inform the insured & insured will have to settle the hospital bill in full and subsequently raise a reimbursement claim after discharge in case of doubt.

After discharge, the hospital will send all the documents related to the claim to Insurance Company/Third Party Administrator for settlement.

At the time of discharge, the customer has to check and sign the original bills and the discharge summary & carry home a copy of the signed bill, discharge summary and all their investigation reports for future reference.

The information provided by the insurance company will allow the customer to keep a certain amount of money aside for non-medical expenses which are to be borne by the customer from his/her own pocket.

For planned admissions, intimations can be given one week prior & initial authorization amount can be sanctioned from the Insurer/TPA Claims team in coordination with network hospital Insurance help desk.  

Prior information to the insurance company about a planned medical treatment also helps the customer and his/her family member to do away with the hassle of documenting the paperwork of the hospital and treatment which is being rendered.  

The exchange of paperwork is coordinated between the hospital and the insurance company. Therefore, it is advisable and prudent from the customer point of view to get in touch with the insurance company in case of any planned medical treatments.

This pro-activeness will ensure hassle-free treatment at the hospital and all the necessary paper required by the insurance company is being seamless coordinated with the hospital.

The only paper that the insured will have to sign at the hospital will be the discharge card of the hospital. Insured need to pay for all pre- and post-hospitalization expenses. These can be claimed only after the settlement of the main hospitalization claim.

Nowadays Insurance Companies & Third party administrators have special agreements with network hospitals for total cashless facility I.e. Insured avails cashless treatment at network hospitals & walk back home without paying a single penny.

These network hospitals are named as preferred network hospitals, also popularly known as Agreed network hospitals & Green channel network.

Also ReadCashless Hospitals need to obtain pre-entry level certificate issued by NABH or State Level Certificate issued by NHSRC in 12 months

Insurance companies have the memorandum of understanding with network hospitals for selective surgical treatments & some medical conditions at fixed rates with concealed packages.

Cashless treatment with networks hospitals is considered complete hassle free.  The list of these hospitals is also displayed on the websites of Insurance companies & TPA’s for information to Insured. During the stay of insured in hospital, few companies extend a facility for a patient visit.

For medical treatments that have been taken at a non-networked hospital, a customer can file an insurance claim for reimbursing the amount taken for the treatment.

For Reimbursement claims too, a customer or member of his/her family is expected to call up the insurance company and inform about the hospital admission to the company.

This intimation will trigger an expecting claim to come at the backend operations of an insurance company and the company will issue a Claim No. or a Claim Unique ID for future correspondence with the company and the insured with regards to the reimbursement claim.

On intimation, the insurance company will guide the insured or his/her family member on the Reimbursement process. This includes filling up the Reimbursement Claim form of the insurance company, the necessary papers required as supporting documents related to the treatment and the postal address where the Reimbursement documents need to be couriered.

Claim forms are readily made available by the Company to the customers in the policy kit along with other policy documents. If misplaced, the reimbursement claim form can be downloaded from the insurance company website or at the branch offices of the insurance company.

In the Reimbursement process, every document prior to the treatment of the illness, during the treatment and post the treatment is essential to be shared with the insurance company.

This includes treating doctors diagnosis of the illness, medical test/X-rays/Scans etc. For reimbursement claims, the insurance company will ask for a Cancelled Bank Cheque to also be sent across. This is for ensuring the bank details of the customers and crediting the payments to the customer’s account directly via NEFT.

Once the patient is at home, the insured or the family member can arrange all the documents of the treatment in chronological order and courier the same to the insurance company along with the filled Reimbursement form mentioning the Claim No. generated at the time of intimating the claim with the insurance company.

On receiving the documents from the customer, the insurance company will study the documents and if the need arises might ask for additional information which the customer might have intentionally or unintentionally forgotten to send across.

Once the claim is studied and approved, the insurance company would check the final amount of reimbursement the customer is entitled as per policy terms and conditions of the policy opted by the customer.


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