Cashless claim facility is available only in the empaneled or network hospitals of the insurance company. One can check on the website of the insurance company or TPA or call on their customer service number to know whether a particular hospital is a part of their network.
The claims process under the cashless facility varies according to the type of hospitalization i.e planned or unplanned. Planned hospitalization usually happens in case of surgeries such as cataract removal, hernia, tonsillitis, etc. Unplanned hospitalization is naturally a result of emergencies such as an accident, sudden illness, etc.
The cashless claims process for planned hospitalization at a network hospital:
The insured has to inform the insurance company about the nature of hospitalization and treatment at least 4-5 days in advance. Usually, a pre-authorization or cashless claim form has to be submitted to the insurance company. It is best to check with the company’s customer service for the list of requirements as this may vary across companies.
Once the company scrutinizes the form/documents and clears it, an intimation is sent by the company to the insured and the concerned hospital with details of the eligibility amount. On the day of the admission to the hospital, the insured has to show the hospital his/her health insurance card and the confirmation letter provided by the insurance company. The treatment can then be sought and the medical bills are directly reimbursed by the insurance company to the hospital.
The cashless claims process for unplanned/emergency hospitalization at a network hospital:
The policyholder can check with the customer service of the insurance company about the nearest or most suitable network hospital. Once in the hospital, the health insurance policy details or e-card should be shown to the hospital authorities who in turn will fill the requisite forms and get in touch with the insurance company.
The insurance company will accordingly provide an authorization letter to the hospital indicating the policy cover details and eligibility amount. The medical bills are directly reimbursed by the insurance company to the hospital. In case of rejection of a claim, the insurance company sends an intimation to the insured with the reasons for rejection.