Cashless Health Insurance Claim Challenges

As more and more insurance providers have added rich features and better benefits to their products in order to attract customers, policy buyers have also become more aware and research-oriented when it comes to choosing health insurance policies . Among the many convenient benefits of a health insurance policy is the ability of cashless health insurance claims.A cashless health insurance policy is a policy in which the policy holder does not have to pay any money to the hospital for their medical expenses. The insurance company directly communicates with the hospital and pays the bill on your behalf. There are no funds exchanged between you and hospital and thus it is termed as a cashless claim.

There are two main types of cashless health insurance in India.

Cashless Health Insurance for Senior Citizens

This is a type of health insurance that allows for cashless coverage of hospitalisation and ambulance expenses for senior citizens. Such policies may also cover pre-existing diseases with a waiting period.

Cashless Family Health Insurance

It is a type of cashless health insurance that is designed to cover members of a family. Under such a family floater plan, parents, children and sometimes even grandparents and in-laws are covered under the same family insurance plan.

In cases of cashless claim settlement, the procedure can be carried out in two ways:

a) Via Preferred Provider Network or PPN

In this method, the insurance provider is associated with a network of hospitals that allow the cashless facility and the policyholder must get their treatment from a network hospital to avail the cashless claim benefit.

b) Third Party Administrator (TPA)

In this method, there is a third party mediator that handles the cashless claim settlement between the hospital and the policyholder.

Even though a cashless claim feature looks attractive and is designed to streamline the claims process, there may be some obstacles that arise during the process.

- Delay in cashless claim approval

Third Party Administrators have to complete all the paperwork and evaluations and approve the claim as quickly as possible so that you can get the cashless benefit on time. But this does not always happen. There may be a delay in the process which might require you to pay out of pocket for the time being. The insurer would of course reimburse you the expenses after the necessary evaluations.

- Partial Claim Settlement

Some insurance providers have a clause stating that only a part of the coverage amount can be claimed via the cashless facility. The rest must be paid out of pocket by the policyholder and will be reimbursed later. Many policyholders might see this as a challenge especially when it comes to emergency insurance claims.

- Unavailability of Network Hospitals

Sometimes a network hospital that supports the cashless facility of your insurer may not be available near you. In cases of emergency, you will have to find the nearest hospital possible and if it is not a network hospital, you will have to pay the bills and get reimbursed later.

-Document related challenges

Your paperwork must be strong when claiming a cashless facility. A duly filled pre-authorization must be submitted to the TPA as soon as possible. Failure to do so could lead to a few hassles during the claim process.

In order to avoid the hassles of a cashless claim facility, a policyholder must be aware of all the terms, conditions and procedures to be followed when claiming a policy. Go through every word of your policy to find out what is included, what is the waiting period and what is excluded. This will give you an idea of what to expect when claiming a policy.Additionally, before you buy a policy, find out if there is a network hospital near you that you can reach in time for emergency treatment. A little planning will help you a long way in making the most of your policy.Call your insurance provider and ask them to explain thoroughly what needs to be done if you want to claim your policy. Write down the pointers in your phone and when the need arises, look at the pointers so that you do not panic and know exactly what to do.

Thus, a cashless claim facility has become quite popular due to the ease of claim that it has allowed. Yes, there may be some obvious obstacles in your way but a thorough understanding of your policy and choosing a reputed insurer as well as a good hospital will ensure that your claims process will go smoothly and you can focus on your well-being.

The information contained herein is generic in nature and is meant for educational purposes only. Nothing here is to be construed as an investment or financial or taxation advice nor to be considered as an invitation or solicitation or advertisement for any financial product. Readers are advised to exercise discretion and should seek independent professional advice prior to making any investment decision in relation to any financial product. Aditya Birla Capital Group is not liable for any decision arising out of the use of this information.