Processing Cashless or reimbursement health insurance claims?

During this pandemic, Health Insurance has become nothing short of a boon to the general population. People are more aware and now understand that having a Health Insurance is absolutely necessary. Even if we discount the pandemic, illnesses can emerge suddenly and one should be prepared. I have seen first hand, how healthy individuals develop sudden complications, and if the insurance is not in place, it may turn the world upside down. Specially if you are young or don’t have enough savings.

If one is paying the insurance premiums regularly then there is a natural expectation that all expenses would be covered. However, this may not be the case always and one needs to be ready for few out of pocket expenses also. Here, I will share my experiences of getting both the cashless and reimbursement claim process done in India.

Things to keep in mind:

1. Always go with a Health Insurance provider who has a good claim ratio. Meaning if the claim ratio is 99.9% then you can safely assume that rejections are only 0.1%. Hence, we need to know that rejections are very low for the claims in your policy.
2. Always read the policy document and check for any exclusions. Certain day care treatments and surgeries might not be covered.
3. Always have adequate cover for yourself and family. It will depend on the amount of savings you have and age bracket. Consult friends and relatives for the same.

There can be two main types of Insurance claims –

Reimbursement claims:

Reimbursement claims involve initial out of pocket medical expenses by self and claiming the same later from the insurance provider. One should send original hospital bills and discharge summary(provided by hospital) to the insurance provider within 30 days of discharge. Else, they may also inquire regarding the delay in submission of documents, which further delays the process. Ask your hospital to give itemized breakup in the final bill provided. Also, keep the medicine bills handy for submission. Expect additional queries to come in later and you may have to submit more documents. The entire process can take anywhere from 1.5 to 4 months. More, if documentation is not submitted properly. One may receive complete or partial amount as reimbursement, as limits are fixed for different components of the medical bill. For example, there may be a limit to per day hospital room expense in your policy.

Cashless claims:

I find cashless claims to be the easiest. However, this facility is available only in approved hospitals. The cashless hospitals are approved by the Insurance provider and one can get a complete list on the website of provider. One, can also inquire in the hospital regarding cashless facility, before getting admission.

1. Ideally one should inform the insurance provider 2-4 days prior regarding a possible admission to a hospital. This can be done via call, email or TPA (Third party administrator) in the hospital. Every cashless facility hospital would have a TPA office separately. In case of emergency/sudden admission, please inform the hospital TPA within 24 hours of admission.
2. Share your policy number and/or claim number(if prior intimation to insurance provider was done) with TPA.
3. Share your ID proofs.
4. Copy of FIR/Legal document , if required
5. TPA will take itemized bill details and other charges directly from hospital staff, when sharing with insurance provider.
6. Share cancelled cheque , if requested.
7. Resolve any query raised with the help of TPA and hospital.
8. One can request for enhancement, if current authorization is not adequate.
9. The TPA will inform regarding approved amount in couple of days from request.

You will also receive an email of the approved amount instantly. There may be pre approval and final approval. They may not reimburse hospital admission charges, which will be clearly mentioned in the email to you.

After all the above procedures are done and patient is cleared to leave, the hospital will confirm cashless discharge.

I hope the above details will help you avoid last minute confusions.