Cashless Process in Mediclaim - Health Insurance
Posted by Deepak Mendiratta on 21 November 2020 04:42 PM

Cashless hospitalization 

This is a facility extended by the insurance company and a part of your policy terms, whereby the policy holder can get admitted and undergo necessary treatment without paying the hospital directly for the medical expenses. The eligible medical expenditure which is incurred is settled by the insurance company directly with the hospital. You can avail cashless hospitalization only in the hospitals that are part of your TPA ( Third Party Administrator ) or Insurers network.

Please find below the procedure of cashless claim process

  • To avail the cashless facility, you can walk-in to any of the nearest network hospital.  List of hospitals
  • Carry your Mediclaim cards along with any Government of India photo Identity proof.  
  • Please inform at the hospital reception ( or TPA / Insurer Helpdesk) that you are covered under Group Medical Insurance policy
  • Ask for pre-authorization form and get it filled by your treating doctor along with medical reports in support of diagnosed. Many Hospitals get this process done by themselves but you can check for particulars at the hospital you are going to
  • Mail the scanned copy of pre-authorization and medical reports to your respective TPA. This too is often handled by the hospital itself
  • Insurer / TPA will then evaluate the details mentioned in the form and process your claim within 4 hours - 6 hours ( this is typically a conservative estimate of time and can often happen much sooner) or intimate you further. This intimation could potentially be a request for more information or a denial of cashless. No denial can happen unless the treatment is not covered specifically under the policy terms. We will be happy to help in case that was to happen to re-validate the opinion of the insurance company and to challenge it on your behalf
  • The cashless may be rejected if Insurer / TPA is of the view that the ailment/ hospitalization are not covered under this policy.
  • At the time of discharge if the claim amount is more that your sanctioned amount, the Insurer / TPA will mention it in the approval note and you may have to bear that yourself. The common head's under which this partial approval may happen are -
    1. Your sum insured is exhausted
    2. Non Medical Items that are not covered under the scope of any health insurance cover in India
    3. There is a provision of cost bearing on your part, as a policy feature under your policy, often called co-payment or deductible
    4. There is a capping for the particular treatment in your policy
  • Few hospital  may ask for initial deposit at the time of admission. This is a subjective demand and varies from hospital to hospital. Any amount that you have paid, after adjustment for the details mentioned in the previous point above, will be refunded to you.
  • At the time of discharge - The patient and family are obviously eager to get home at this point in time. We would like you to calibrate your expectations on this. While the treating doctor may advise discharge the previous day or the same day, there sequence of processes that a hospital needs to follow are many. THis process itself at the hospitals end, often can take a few hours. Finally once the hospital generates the final bill and discharge summary, they will send it to the Insurance company / TPA. This is then put into a detailed scrutiny by them and a doctor will also evaluate all the documents. Once they have validated all details and mapped it against the policy terms, they will approve the claim and also the amount that they will pay. THis will then result in the Final Authorization being sent to the hospital.
  • On receipt of the Final Approval / Authorization, the hospital will let you know via the billing department if you need to pay any balance, assuming the approval is done. You can pay that balance or challenge it ( in which case seek us out and we will understand your point of view and represent it to the Insurer / TPA)

Finally you can be on your way home !

Do remember, once the authorization comes in and you are back home, almost all policies have a provision of pre and post hospitalization expenses. These are those expenses that you may have or will incur before and after hospitalization. These expenses are on OPD basis and may relate to doctor fees, investigation charges, drugs etc, which are directly related to the treatment undergone by the policyholder.Do check with us and we will help you file those as well.

The processes are tedious and cumbersome. There may be delays from any of the stakeholders. Already handling the emotional challenges during such times, we know it can be frustrating to handle these processes too. Our team is here to help and we will do whatever it takes to ensure you don’t have to handle this by yourself

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We wish speedy recovery and Happy Health

Team PlanCover

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