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The world we live in today necessitates a health insurance policy. And while many of us stay invested in comprehensive health plans, making a claim can often raise some questions and confusion in the mind. One of the common questions can be about the claim settlement. When you buy health insurance, you will also learn about the claim settlement process. Typically, there are two ways in which a health insurance claim can be made: cashless claim and reimbursement claim. Read on to understand what is health insurance reimbursement and cashless claims.
Before we discuss what is reimbursement in healthcare, let us first take a look at what is latest in the health insurance industry.
What is ‘Cashless Everywhere’?
‘Cashless Everywhere’ is an innovation that was recently announced by the General Insurance Council of India. This initiative will allow policyholders to seek cashless treatment even in non-network hospitals. The advantage of cashless hospitalisation is so far, available only in the network hospitals. These hospitals or chains of hospitals allowed treatment to the insured as per their policy. The medical bills were cleared directly by the health insurance company.
While the announcement is considered to be a groundbreaking move, there are certain things that as a customer, you should keep in mind:
- Make sure you inform your insurance provider at least 48 hours before the admission to the hospital. In case of a medical emergency, you can inform the company within 48 hours of admission.
- The chosen hospital should be registered, and should have a minimum of 15 beds.
- The claim settlement will be done according to the terms and conditions of your existing policy.
What is a Cashless Claim in Health Insurance?
Cashless Claims are a type of health insurance claim in which you receive treatment at a network hospital without the need to pay for hospital expenses. Under this, the hospital settles it by sending the costs incurred directly to the insurer.
To get the benefits of a cashless claim, you can visit a hospital that is a part of your insurer's network and submit your identification proof and health e-card. Nevertheless, before proceeding, note that you need to get your health insurer's approval in advance. For planned treatments, this needs to be done about 72 hours before the hospitalization. As for unplanned medical emergencies, you should request permission within 24 hours of hospitalization.
After receiving the treatment, your health insurance company or the authorized third-party administrator (TPA) acts as a bridge between your health insurer and the hospital. They will process the paperwork and required claim forms. Subject to the terms and conditions of the policy, the insurer then settles the medical expense with the hospital directly. Cashless claims guarantee that the policyholder will not have to worry about collecting funds under unforeseen medical emergencies. However, the claims are subject to copayments and policy deductibles.
>> Also Read: Cashless Treatment in Network Hospitals
What is Reimbursement in Health Insurance?
Let us now discuss what are reimbursements in healthcare. Reimbursement claims are a type of health insurance claim where you seek treatment in a hospital that is not networked with your insurer. Under this, you can choose any hospital for treatment and pay the initial costs. Subsequently, you can submit a claim to your insurance provider to reimburse all your expenses.
To go ahead with this process, you need to submit all the necessary documentation, including hospital bills, medical records, discharge summary and prescriptions. The insurer will then examine and approve these documents as per the terms and conditions of the policy. However, this process of verification could extend the claim settlement duration substantially.
While this option offers greater flexibility in terms of selecting a healthcare provider of your choice, the settlement takes a little longer. Additionally, it is crucial to note that reimbursement claims are subject to copayments and policy deductibles. Policyholders might have to pay a portion of the expenses out of their pockets.
Differences Between Cashless and Reimbursement Claims
Given below are some of the main differences between Cashless Claims and Reimbursement Claims:
| Factors | Cashless Claims | Reimbursement Claims |
|---|---|---|
| Claim Filing | Easier because the claims are settled directly between the insurance company and the hospital. | Challenging because the policyholder needs to manage the claim themselves. |
| Claim Process | Policyholders need to inform the insurers prior to hospitalisation and file a claim. | Policyholders file a reimbursement claim after the treatment with the bills and receipts. |
| Claim Settlement | Insurers settle the treatment expenses as per the terms and conditions of the policy. | Policyholders pay hospital bills upfront and then file for the claim. |
| Claim Approval | 72 hours earlier (planned hospitalisation), and within 24 hours (medical emergency) | No claim approval is required, however, informing your health insurance provider is essential |
| Documents required | Health insurance card, policy details and other details as requested by the hospital. | Health invoices, medical bills, doctor prescriptions, and other documents as requested by the insurer. |
| Processing Time | Faster TAT, turnaround time | Slower TAT as compared to cashless claim |
| Expenses | Subject to terms and conditions of the policy. | Subject to copayments and policy deductibles. |
| Hospital Availability | With the introduction of cashless everywhere, cashless hospitals are not restricted to a network | Policyholders can choose any hospital of their choice. |
Which Claim Should You Raise: Cashless or Reimbursement?
Once you understand what is a cashless claim and what is reimbursement in health insurance, you will be in a better position to see that both these claim procedures hold value. A cashless claim surely can be a blessing, especially when you are in a medical emergency. Arranging funds at the eleventh hour can be a major worry, especially in a situation when you are already stressed. However, certain administrative glitches can occur when making a cashless claim. A delayed discharge is often a problem that policyholders face when a cashless claim is settled.
With the announcement of cashless everywhere, the concept of ‘network hospitals’ may soon fade away. As a policyholder, you will now be allowed to seek cashless treatment in any hospital. However, do keep in mind the required criteria when you wish to take advantage of this facility. There may be hospitals where you might not be able to avail of the cashless facility, or you want to pay the bills upfront to speed up the discharge or out of your own choice. In such a scenario, you have the option to opt for a reimbursement claim. Simply put, choosing between cashless and reimbursement claims can be your personal choice, so make sure you weigh the pros and cons of each and then take a call.
Wrapping Up!
The introduction of cashless everywhere will surely help policyholders with a more streamlined and easy claim settlement process. With Care Health Insurance, you have the freedom to choose a claim settlement process of your choice. We strive to offer all our customers an easy and hassle-free claim experience, whether it is cashless or reimbursement. Just make sure you understand the formalities involved with both procedures and follow them properly. For any more questions and concerns, get in touch with our customer care team today.
We wish you good health!
Disclaimer: All plan features, benefits, coverage, and claims underwriting are subject to policy terms and conditions. Kindly refer to the brochure, sales prospectus, and policy documents carefully.
