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Cashless vs Reimbursement Claims in Health Insurance

Oct 24, 2024

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Cashless vs Reimbursement Claims in Health Insurance
Contents

Every Policyholder expects their Health Insurance Policy to settle their Insurance Claims promptly and quickly in case of a medical emergency. It is important that the Insured is aware about the Claim Settlement Process to avail the benefits of a Health Insurance Policy.

There are two types of claim settlement processes under a Health Insurance Policy:

  1. Cashless Claim Settlement
  2. Reimbursement Claim Settlement

This article explains both types of claims in detail in a Health Insurance Policy.

What is a Cashless Claim?

A Cashless Claim is a type of an Insurance Claim where the Policyholder gets treated at a network hospital without having to pay any of the hospitalisation expenses out of his own pocket. Rather, the Insurance Company directly settles the Claim with the hospital for all the medical expenses. In order to avail cashless claim settlement, it is necessary that the Insured visit a hospital which is part of the Insurance Company’s network. You can check the Insurance Company’s Network Hospital list on Insurance Company’s website. The advantage of cashless claim settlement is that the Insured does not have to bear any of the hospitalisation expenses out of his own pocket since the Insurance Company directly settles the claim with the hospital

How to avail Cashless Claim Settlement under a Health Insurance Policy?

The Policyholder should follow the below mentioned steps in order to avail cashless claim settlement under a Health Insurance Policy:

  1. Get admitted at the nearest network hospital covered by the Insurance Policy to avail treatment
  2. Intimate the Insurance Company about the claim by either providing the relevant details on the Insurance Company’s website or sending an email to the registered Email ID of the Insurance Company
  3. The Insurance Company provides a Claim Intimation number upon successful registration of the Claim
  4. Show the Health Card issued by the Insurance Company to the insurance desk at the hospital.
  5. Fill the Pre-Authorization Claim Form provided by the hospital. The Hospital sends the Pre-Authorization Claim Form to the Insurance Company for Claim Settlement
  6. The Insurance Company will inspect the details and inform the Insured about the approval or rejection of the Claim
  7. Once the Claim gets approved, the hospital sends the expenses and receipts to the Insurer and the hospital gets reimbursed for the treatment expenses directly by the Insurance Company.

What is a Reimbursement Claim?

A Reimbursement Claim is a type of Health Insurance Claim where the Policyholder avails treatment at a hospital, pays all the expenses out of his own pocket, submits the necessary documents to the Insurance Company, after which the Insurance Company reimburses the Insured for all the expenses incurred. Under a Reimbursement Claim, the Policyholder has to pay all the hospitalisation expenses out of his own pocket and then submit all the relevant documents to the Insurance Company to claim reimbursement under the Health Insurance Policy. The advantage of Reimbursement Claim is that the Insured can avail treatment at any hospital and that he is not restricted to the Insurer’s network hospitals, like in a Cashless Claim. The Policyholder can go to any hospital for treatment, pay the bills himself, and then submit a claim to the Insurance Company for reimbursement.

How to avail Reimbursement Claim Settlement under a Health Insurance Policy?

The Reimbursement Claim Settlement Process under a Health Insurance Policy is listed below:

  1. Inform the Insurance Company within 24 hours of admission to the hospital. The Company will provide the Policyholder with a Claim Intimation Number after the claim is raised so that the Claim Status can be tracked.
  2. Make the payment to the hospital for the medical expenses incurred and keep original copies of all the Invoices.
  3. Submit the necessary documents to the Insurance Company
  4. The Insurance Company will verify the Claim Details, ask for additional documents if required and will approve or reject the Claim.
  5. The approved Claim Amount gets credited directly to the Bank Account of the Insured

What are the documents Required for a Reimbursement Claim under a Health Insurance Policy?

The Insured needs to submit the following documents to the Insurance Company to avail Reimbursement Claim Settlement under the Policy:

  1. ID Proof, Policy Health Card and Address Proof
  2. Duly Filled and Signed Claim Form
  3. Pathology Reports
  4. Medicine Prescriptions and Pharmacy Bills
  5. Pre and Post-Hospitalisation Bills
  6. Hospital Bills
  7. Discharge Summary

Cashless vs Reimbursement Claim Process

Cashless vs Reimbursement Claims in a Health Insurance Policy

Cashless Claims Reimbursement Claims
What is it? Under a Cashless Claim Process, the Policyholder avails treatment at a Network Hospital and the Insurance Company settles the Claim with the hospital directly. Under a Reimbursement Claim Process, the Policyholder pays the hospital bills out of his own pocket. After that, the Policyholder submits these bills to the Insurance Company to along with any relevant medical records to avail reimbursement fir expenses incurred.
How is the Claim Settled? The Insurance Company directly settles the Claim with the hospital After paying hospital bills himself, the Insured submits claims to get reimbursed by the Insurance Company.
What is the Claims Settlement Process? The Insured needs to show the Health Card to the Insurance Desk at the hospital. The Hospital After treatment, the Insured applies for reimbursement by submitting original invoices, reports, other necessary documents.
How much Time does it take for Claims Settlement? Faster than reimbursement Claims Process. Usually longer than Cashless Claims Process.
Where can you avail Claim Settlement? Cashless Claim Settlement is limited at hospitals included within the insurer’s network. Treatement can be availed at any hospital under Reimbursement Claims Settlement.

Conclusion

It is important to be aware of the Claim Settlement Process in a Health Insurance Policy so that you can easily avail claims under the Policy when a need arises. A Cashless Claim does not require you to bear expenses out of your own pocket and it is quicker and more convenient. The network hospital requirement is the sole drawback of a cashless claim, so be sure to research the hospital network in advance. In the case of reimbursement, you will be required bear the medical expenses out of your own pocket and the file for reimbursement later. To avail a Reimbursement Claim, you must submit all the necessary bills, prescriptions, reports and other documents to the Insurance Company. So, make sure, that you maintain a proper record of all the documents. If you require any further information about Cashless or Reimbursement Claims Settlement Process under a Health Insurance Policy, please reach out to us via email at insurance@qian.co.in or call us on 022-35134695. We would be glad to assist you.

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