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Procedures of availing cashless claim of your Health Insurance Policy

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Purpose of Health insurance is to avail monetary support during period of treatment in hospital. Health insurance is an indemnity product which means that Insurance Company indemnifies the monetary expenses incurred on account of medical treatment. It also means that insured cannot take any gain out of such arrangement. Health Insurance Claim can be availed through cashless arrangement and/or through reimbursement. Cashless is a smooth system where Insurance Company directly pays to the hospital without any monetary pressure to the family of insured.

3 Points to Remember While availing cashless health insurance claim

To understand cashless claim, insured need to remember three critical points :

  1. Cashless claim can only be availed in a network hospital so insured should have a list of hospitals which are in the panel of your insurer. One can always check the updated list through website or call center or by checking from the helpdesk of hospital.
  2. Policy document or Medical Card should be kept at a convenient place and should be in the knowledge of family. All Insurance Companies issue the medical card for each insured in the policy. If you do not have the card then you can get it reissued. Besides Medical card, Hospitals also seek ID card like Aadhar card, Doctor recommendation for hospitalization, supporting medical papers justifying hospitalization.
  3. Cashless request needs to be made in an Authorisation form which is available at Insurance Helpdesk of Hospital or download it through website of Insurance Company or TPA. This request needs to be made within 24 hours of admission in case of an emergency admission to a hospital. In case of planned admission, request should be made 48 hours prior to admission.
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Expenses Covered under Cashless Health Insurance

Scope of cashless claim – almost all type of treatment and related expenses can be covered under cashless health insurance claim. Given below is the list of expenses which can be covered under cashless claim:

  1. Ambulance charges when booked through Hospital
  2. Pre and Post Hospitalisation when attended by same hospital.
  3. Treatment under day care – specially planned surgeries when authorization is taken 48 hours in advance.
  4. All major surgeries including Dialysis / Chemo unless categorized under exclusions in the Policy document. Insured should refer the Policy Document for exclusions.

Expenses not covered under cashless claim

  1. Basic deductions of non-medical expenses.
  2. Room rent if capped – please note that all expenses are taken on prorata basis. Hence, we should take standard room or go for twin sharing room to save on your associated expenses. This is critical when one have family floater with limited sum assured.
  3. Fixed expenses under some treatment as specified in Policy conditions – for example maternity expenses can be limited to Rs 75000 hence all additional expenses will not be paid by Insurance Company.

 

Precautions for cashless health insurance claim

  1. Please check previous prescriptions specially previous medical history. Many times, attending Doctor make certain remark about patient which may be only symptoms but Insurance Company may consider it as pre-existing and reject the appeal for cashless. For example, Raghvan went to a neighborhood Doctor with complaint of chest pain. When Doctor asked, he admitted that he has this problem of chest pain for last 3 years though he was not taking any medicine or treatment. But Doctor made a remark “ Known case of chest pain and cardiac problem for last three years “. Raghvan had a cardiac arrest and submitted Doctor prescription. Claim was rejected on ground that Cardiac Problem was pre existing because policy was taken only two year ago.
  2. Choose a Network Hospital and select a standard room or twin sharing room if sum assured is not more than Rs. 5 lakh.
  3. Ensure that Hospitalisation is required and it is not done for examination purpose. Ensure that attending Doctor is making a diagnosis and recommending Hospitalisation under a standard treatment protocol.
  4. Under Top up schemes, you need to pay the deductible limit or show the certificate that deductible limit has been paid by Insurance Company.
  5. Under Copay system, pay your portion and sign the documents for cashless payment.
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Get Resolutions for Insurance Complaints

In case of any problem, You can always take help of Insurance Desk of Hospital.

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