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All You Needed to Know about a Cashless Mediclaim Policy

Picture this – somebody close to you suddenly falls ill and has to be admitted in the hospital. From where are you going to arrange the cash to avail medical treatment?

Many a times, one has to borrow money from friends and family to pay for hospital expenses. Research suggests that Indian families still meet upwards of 70% of their health expenses out of their own pockets. This has the obvious effect of gradually thrusting these families to the brink of poverty.

To assist individuals during medical emergencies, health insurance companies have come up with the concept of a cashless claim on health policies. In a cashless claim, almost all the hospital charges will be taken care of by the insurer, provided that it does not surpass the sum insured.

Every health insurer ties up with a few thousand hospitals around the country. These are known as network hospitals. It is at these hospitals that policyholders can avail the cashless treatment facility. To know your health plan's network hospitals, simply download the OneInsure app (Play Store | App Store) and you will have this info in just a few taps.

There are two kinds of cashless claims – Planned and Emergency.

  • Planned Claim – Here, the policyholder is aware of the hospitalisation 3 – 4 days in advance and has to inform the insurer about it along with the details of the hospital s/he will be getting admitted into. The individual is required to fill up the pre-authorisation form, which can be obtained at the hospital desk or the third party administrator's (TPA) website, a few days before the scheduled treatment.
  • Emergency Claim – Here, the policyholder is in need of immediate hospitalisation, which can be due to a serious illness or an accident. The insurance company needs to be informed at the earliest about an emergency treatment (depending on the insurer, this timeframe is between 24 and 48 hours). To avoid encountering any delays, make sure to carry a copy of your ID card / policy copy and KYC of the proposer to the TPA cell of the hospital. You would be asked to fill a pre-authorisation form, which has to be filled and submitted to the TPA cell.

Which Claims Can Be Rejected?

Your claim could get rejected if the information provided in the form is inadequate for the request to be approved by the TPA. Generally, the TPAs ask the hospitals for additional information if the need arises. An insurance company can also deny pay-out if the policyholder has already used up the sum insured for the year or if the policy has expired or lapsed. So, make sure you are aware of your insurance status and always see to it that you are sufficiently covered by your health policy.

To ensure that you never have to face claim denial, make sure to read the policy wording when you buy a health plan. It is your responsibility to ensure that all the necessary documents are submitted to the insurer on time. Lastly, don't forget to keep the cashless card with you at all times.


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