How do Non-Network & Network Hospitals Affect Health Claim?

Today, health insurance companies are mindful that medical establishments tend to charge more for the treatment facilities offered from people who have health insurance coverage than those who don’t have insurance. Therefore, to prevent the losses, the insurance companies tie-up with different hospitals and make them a part of their network.Thus, the hospitals that collaborate with the insurance companies are known as ‘network hospitals.’ Hospitals that are not included in the insurer’s network are non-network hospitals.

Typically, the insurers offer cashless treatment facilities at the network hospitals. This means during a medical emergency; you can get admitted to the network hospital and inform the TPA (Third Party Administrator) about the cashless claim. Upon discharge, the TPA will collect the necessary bills from the hospital, and the insurer will settle the full amount with the hospital directly.In another situation, assume that you get admitted to a network hospital, but your plan does not offer a cashless facility. In such cases, you must pay the medical bill from your pocket initially and submit the invoices and other relevant documents to the insurer, and file for reimbursement. Upon verifying the bills, the insurer will repay the amount as per the policy’s terms and conditions.In both the above cases, you will not get compensation for the expenses that are explicitly not included in the policy scope.Often, during an emergency, people tend to rush to the nearest hospital, which may not be part of the insurer’s network, to get immediate treatment. In such a situation, irrespective of whether your plan offers a cashless facility or not, you will not get the benefit as you seek treatment from a non-network hospital.In this case, when you file for reimbursement, the insurer will do a microscopic review of the expenses incurred and approve only those costs that are found reasonable as per the standard practice and the policy terms. The insurer may either approve the full cost or only a part of it based on their assessment of the expenses and the hospital charges.The insurer will provide the reason for rejection of a specific cost, and despite having sufficient cover, you would have to bear those expenses.

Thus, it is quite evident from the above examples that getting treatment from a network hospital is better, especially if it is a planned hospitalisation. You get the advantage of using the cashless facility. Also, the reimbursement process is easy and hassle-free.

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.