What are Steps to File a Cashless Claim for Health Insurance
Here's how to file a cashless health insurance claim for both planned and emergency hospitalizations:
Planned hospitalization
- Inform insurer: Notify your insurance company at least 48 hours before hospitalization via their toll-free number.
- Pre-authorization Form: Obtain a pre-authorization form from the hospital's insurance desk or download it from the insurer's website.
- Submit form: Submit the filled form and your health card to the hospital's insurance desk.
- Verification and approval: The insurer/TPA will verify the details and approve or reject the pre-authorization.
- Authorization letter: If approved, you'll receive an authorization letter specifying the approved treatment amount.
- Treatment and discharge: Receive treatment and sign all required documents upon discharge. The insurer will settle the bill directly with the hospital.
Emergency hospitalization
- Inform insurer: Inform the insurance company within 24 hours of emergency hospitalization.
- Health card: Present your health insurance card at the hospital.
- Pre-authorization form: Fill and submit the pre-authorization form at the insurance desk.
- Hospital submission: The hospital submits the form to the insurer/TPA for approval.
- Verification and approval: The insurer/TPA verifies the details and approves or rejects the request.
- Treatment and discharge: If approved, receive treatment and sign documents upon discharge. The insurer will settle the bill.
What are the inclusions of cashless health policy?
Cashless health insurance provides coverage for a wide range of medical expenses, offering financial protection and peace of mind during times of need. Here's a breakdown of the typical inclusions:
· In-patient hospitalization: Covers expenses related to room rent, nursing care, doctor's fees, surgery costs, medicines, and other medical treatments during hospitalization.
· Pre- and post-hospitalization: Covers medical expenses incurred before and after hospitalization, such as doctor consultations, diagnostic tests, and medications.
· Day-care procedures: Covers expenses for procedures that don't require 24-hour hospitalization, such as chemotherapy, dialysis, and cataract surgery.
· Ambulance charges: Covers the cost of ambulance services for transporting the insured to the hospital in case of an emergency.
· Critical illnesses: Many policies offer coverage for specific critical illnesses like cancer, heart attack, and stroke, providing a lump sum benefit upon diagnosis.
· Maternity benefits: Some maternity insurance plans include coverage for pregnancy, childbirth, and newborn care, helping manage hospitalization and delivery expenses with ease.
· Alternative treatments: Certain policies may cover alternative treatments like Ayurveda, Unani, Siddha, and Homeopathy, subject to terms and conditions.
Wellness programs: Many insurers offer wellness benefits like health check-ups, preventive screenings, and discounts on fitness programs to promote healthy living.
What are the exclusions of cashless health policy?
Cashless medical insurance policies come with specific exclusions that are important to understand. These typically include:
- Pre-existing conditions
Any medical conditions that existed before the policy was purchased are usually not covered right away. Most policies have a waiting period before such conditions become eligible for claims. - Cosmetic or aesthetic procedures
Expenses related to cosmetic surgeries or treatments performed for enhancement or appearance—such as plastic surgery—are generally excluded unless medically necessary due to an accident. - Non-medical expenses
Items like toiletries, special diet meals, registration fees, and other personal comfort-related costs during hospitalisation are not reimbursed, as they are considered non-medical. - Self-inflicted injuries
Injuries arising from self-harm, suicide attempts, or intentional harm are not covered under most health insurance policies. - Dental treatments
Routine dental procedures, including cleaning, extraction, or cosmetic dental work, are usually not included unless they are required due to an accident or injury. - Alternative treatments
Therapies like Ayurveda, Homeopathy, Unani, or Acupuncture may not be covered unless explicitly mentioned in the policy under AYUSH or a similar rider. - Lifestyle-related conditions
Health issues caused by substance abuse, excessive alcohol consumption, or drug misuse are typically excluded from coverage. - Maternity & childbirth
Unless the policy specifically includes a maternity benefit, expenses related to pregnancy, delivery, and newborn care are not covered under standard cashless plans.
Understanding these exclusions helps avoid surprises during claims.
Cashless insurance process during planned hospitalisation
Cashless health insurance isn’t just useful during emergencies—it’s equally helpful for planned medical treatments or surgeries. Here's how the process works in easy-to-understand steps:
- Pre-authorization request
Before your scheduled hospitalisation, you need to complete a pre-authorization process. This involves sharing your treatment plan and medical documents with your insurance provider to seek approval for cashless coverage. - Select a network hospital
Choose a hospital from your insurer’s empanelled (network) list. These hospitals have tie-ups with your insurance company, ensuring a smooth and cashless treatment process. - Submit required documents
At the hospital, provide the necessary documents such as:
- Treatment approval from insurer
Once all documents are submitted, the hospital sends them to the insurer for approval. Upon verification, your insurance provider confirms coverage for the planned procedure. - Undergo cashless treatment
With approval in place, you can proceed with treatment without paying anything upfront. The hospital directly bills the insurer for the expenses covered under your policy. - Track out-of-pocket expenses
Keep an eye on any charges not included in your policy—like non-medical items (e.g., toiletries) or optional services—which you’ll need to pay separately. - Post-treatment documentation
After discharge, ensure that the hospital and insurer complete all final paperwork and billing to avoid any claim delays or settlement issues.
Cashless Insurance Process During Emergency Hospitalisation
Cashless health insurance can be a true lifesaver in emergencies, allowing you to get immediate treatment without worrying about arranging money on the spot. Here’s how it works in simple steps:
1. Immediate admission
Head straight to a network hospital—these are hospitals partnered with your insurance provider and authorised to offer cashless services.
2. Notify hospital staff
Inform the hospital that you have cashless health insurance. Present your health insurance card or share your policy details at the helpdesk.
3. Submit essential documents
Provide necessary documents such as:
- Government ID proof
- Doctor’s prescription (if available)
- Medical reports or emergency diagnosis
These help the hospital initiate the cashless claim process with your insurer.
4. Begin immediate treatment
Once your insurance details are verified, the hospital begins your treatment without waiting for payment—ensuring you get the care you need on time.
5. Insurance coordination & approval
The hospital coordinates with your insurance company to get approval for emergency treatment expenses. This ensures your medical bills are covered as per policy terms.
6. Hassle-free care
You receive continuous treatment without the burden of paying upfront. The hospital sends bills directly to the insurer for settlement of covered expenses.
7. Monitor extra charges
Keep an eye on any non-covered costs, such as consumables or personal requests, which may need to be paid out-of-pocket.
8. Post-treatment processing
After discharge, confirm that all bills and documents are correctly submitted and processed to ensure smooth claim settlement without delays.
The process to avail cashless health insurance
To raise a cashless claim request, you can follow these simple steps:
Step 1: Search for a partner hospital in your city and inform the insurance provider within 48 hours of hospitalisation (for emergency situations) or at least three days prior to admission (for planned hospitalisation).
Step 2: Make sure to carry the policy details or the patient's insurance cashless card provided with the policy document when you visit the network hospital.
Step 3: Produce a valid ID proof and insurance cashless card at the insurance desk of the hospital.
Step 4: Fill up all the details in the pre-authorisation form and submit it at the hospital.
Step 5: To expedite the procedure, fill up a request form on the official portal and inform your insurer about the same.
Step 6: Your insurance provider might take a few hours to review an application and inform you accordingly via SMS and e-mail.
Step 7: You can even check the status of the claim online.
The insurer will process the claim as per the terms and conditions after the completion of all the formalities.
Importance of having a cashless health insurance plan
Due to rising medical expenditures and emergencies, people are frequently in need of money and struggle to pay for medical expenses effectively. This sometimes results in compromising on the health care you receive. Cashless health insurance plans come in handy in such situations because they allow an individual to receive care without having immediate access to money. To receive the treatment, the policyholder needs to go to one of the network hospitals of the insurer and the procedures will be taken care of.
This facility allows the insured to feel less stressed and have peace of mind. Additionally, it will save time, effort, and energy while settling the claim with the insurance provider.
The points we have shared with you today are aimed at making sure that when you put your health insurance to the test during an emergency, it gives you the financial security you need without any hassles. To choose a health insurance plan that’s got you covered well in all these aspects, visit the Bajaj Finance website. Here, you can explore health insurance plans from our trusted partners, view product features, compare prices and purchase a plan that is best suited to your needs. All this in a matter of minutes and from the comfort of your home. It truly is becoming the new way to buy insurance.
Things to keep in mind before buying a cashless health insurance policy
Before purchasing a cashless medical insurance policy, consider these factors:
- Network hospitals: Ensure the insurer has a wide network of hospitals.
- Coverage details: Check what medical conditions and treatments are covered.
- Exclusions: Be aware of what is not covered under the policy.
- Claim process: Understand the process and documentation required for cashless claims.
These steps will help you select the most suitable policy for your needs.
What is the difference between cashless claims and reimbursement claims?
| Categories | Cashless Claims | Reimbursement Claims |
| Payment Process | Insurer pays the hospital directly. | Policyholder pays the hospital and seeks reimbursement from the insurer. |
| Upfront Payment | Not required at discharge. | Required at the time of discharge. |
| Documentation | Simple: Health card and pre-authorization form. | Extensive: Doctor's notes, bills, payment receipts, claim form. |
| Pre-Approval | Mandatory pre-authorization. | No pre-authorization needed. |
| Convenience | Highly convenient during emergencies. | Less convenient during emergencies. |
| Processing Speed | Fast, typically within hours. | Slower processing time. |
What are the main reasons for claim rejection in a cashless Mediclaim policy?
While cashless health insurance offers convenience, certain factors can lead to claim rejection. Here are some common reasons:
- Policy exclusions: The claimed illness or procedure is not covered by the policy.
- Sum insured exhausted: The policyholder has used up the entire sum insured for the policy period.
- Waiting period: The claim is made during the waiting period specified in the policy.
- Undisclosed pre-existing conditions: Pre-existing diseases were not disclosed during policy purchase.
- Insufficient/incomplete information: Inadequate or incomplete information provided in the pre-authorization form.
- Delayed intimation: Delay in informing the TPA about hospitalization.
- Incorrect information: Providing inaccurate information to the insurer.
- Expired policy: The policy has expired at the time of claim submission.
Tips to avoid cashless health insurance claim rejection?
Follow these tips to ensure your cashless health insurance claims are approved smoothly:
- Disclose pre-existing conditions: Inform your insurer about any pre-existing diseases when purchasing the policy.
- Timely intimation: Notify the insurer promptly about planned hospitalizations (at least 48 hours prior) or emergency hospitalizations (within 24 hours).
- Accurate information: Provide complete and accurate details about your medical condition in the pre-authorization form.
- Check waiting periods: Be aware of the waiting periods for specific treatments and ensure your claim falls outside these periods.
- Understand policy terms: Read your policy documents carefully to know the inclusions and exclusions.
- Renew policy on time: Renew your health insurance policy before it expires to maintain continuous coverage.
