Cashless claim not as easy as you think? Follow these tips

Cashless claim is a very policyholder-friendly feature that spares us from running from pillar to post for mobilising money in times of medical emergencies. However, it is the policy holder who loses everything even if a small mistake is made by either company or third party administrator or policy holders themselves. How can we get a better deal?

Hyderabad: Cashless claim is a very policyholder-friendly feature being offered by insurance companies. It offers big relief in times of medical emergencies and spares us from running from pillar to post for mobilising money in medical emergencies. Under the cashless feature, the insurance companies concerned will pay the hospitalisation bills directly. However, unexpected problems crop up sometimes. What should we do?

One major issue that may arise in cashless policies is partial claim settlement. Here, the company pays a determined amount towards medical treatment costs. The policyholder would have to pay the pending amount towards additional treatment and then make a claim. For example, a company paid Rs 30,000 towards a cashless claim but later the policyholder was admitted to the hospital once again and incurred Rs 10,000 treatment costs additionally. This amount has to be first paid by the policy holder and then approach the company for the claim.

Another caution needed on the part of the policyholders is to join a network hospital approved by the insurance company concerned. If, in any emergency, a patient is admitted to a non-network hospital, the insurance company would not process the cashless claim. Under such circumstances, the policyholder would have to pay treatment costs from their side and then submit claim application along with all the necessary clinical documents and bills. So, the list of network hospital with which a company tied up should be checked in the beginning itself.

Under cashless treatments, the policyholder should make sure to provide the necessary documents to the company to avoid future problems in bill processing. Especially, the policyholder should submit pre-authorisation form to the third party administrator (TPA) without fail. It is better to keep the health cards issued by the TPA handy all the time. In case of normal hospitalisation, the authorisation form and other documents should be submitted to get the benefits under cashless claim processing.

Cashless claim processing poses a challenge in medical emergencies. Some surgeries would have to be done urgently. Doctors may ask for immediate payment of bills to avoid delays. Then, the policyholders can pay directly and claim the amounts from the insurance companies later. For this, it is better to choose a company that has a strong network to settle bills online.

Some treatments are not covered under cashless health claims. Different policies follow different norms in this. Usually, documentation charges, regular check ups and special medical tests will not be covered under cashless claims. So, the policyholders would have to find out in advance about the exemptions if any company offers in this respect.

We should not forget the fact that the policyholder will be the end loser if either insurance company or TPA or policyholder makes a mistake in cashless claims. This is why due diligence should be used to check all facts before taking the health policy itself. One should enquire about the network hospitals, list of diseases covered by the policy and exemptions offered by the companies. At the same time, it is important to follow the protocol set by the insurance company during claim processing.