Cashless Treatments with Health Insurance: A Complete Guide

Imagine visiting a hospital, just focusing on your recovery, without thinking about arranging for cash or worrying about bills. Isn’t that great? The hospital handles the bill directly with your insurer, ensuring a smooth and stress-free experience. That’s the magic of cashless health insurance!  

This guide is your stress-free roadmap to understanding this powerful tool. We’ll break down the benefits, answer your questions about cashless mediclaim, and get you on the path to a smoother, more secure healthcare experience. 

What is a Cashless Insurance Policy?

A study by Forbes has shown that only 514 million Indians were covered by health insurance in 2021, which is approximately 37%.^[1] It was also seen that 48% of healthcare spending in 2019 was from out-of-pocket payment; and this is where a cashless insurance policy can be beneficial.^[2]

It enables the insured to avail of cashless treatment at specific medical facilities. The insurer directly settles the medical bills with the hospital up to the limit specified in the policy. 

Cashless treatment is only available at hospitals with a tie-up with your insurance company. These are known as network hospitals.

Benefits of Cashless Treatment

Let us look at how cashless treatments with health insurance give you hassle-free medical access:

• Convenience in getting treatment 

Cashless hospitalisation simplifies the entire claim process. You don’t have to worry about handling bills or complex paperwork with the hospital. The insurance company takes care of the communication and settlement directly.

• Top-quality care

You can access the best doctors and treatments at network hospitals without the hassle of upfront costs. Additionally, you can avail of cashless treatment even when travelling across India. 

• No financial headache

Your family is also not stressed and does not need to break their savings or other investments due to any medical emergency.

• Tax savings

As per Section 80D of the Income Tax Act 1961, you can avail of tax exemption up to ₹25,000 on the premiums paid to buy a cashless insurance policy.

What is Covered in Cashless Treatments?

Insurance policy providers don’t have one-size-all policies. Hence, you must speak to your provider directly to understand what is covered in your cashless insurance policy. 

Most cashless policies cover:

• Pre and post-hospitalisation expenses (may include doctor consultations and medications)
• Coverage for critical illnesses such as cancer, heart attack, stroke, kidney failure, etc.
• Ambulance cost
• Daycare treatment
• In-patient hospitalisation charges
• Domiciliary hospitalisation, i.e. treatment at home (insurer dependent)
• AYUSH treatment (Coverage for traditional Indian medicine systems like Ayurveda and homoeopathy)

What is Not Covered Under Cashless Insurance Policy?

Cashless health insurance, while convenient, doesn’t cover everything. Here are some standard exclusions:

• Pre-existing diseases: Any disease/surgery/symptoms that occur within 30 days of the policy start date are not covered.
• Self-inflicted harm like suicide attempts
• Diseases related to the abuse of drugs or alcohol
• Pregnancy and infertility treatments
• STIs like HIV/AIDS, etc.
• Medical expenses incurred due to mob strikes, riots, war, and nuclear warfare
• Cosmetic surgeries 

What is the Process of Cashless Claim Settlement?

Here’s a step-by-step breakdown of the cashless process when you need health insurance claim settlement:

• Step 1: Get admitted to a network hospital. For a planned visit, inform at least 72 hours before, and in case of an emergency, you or your family member must notify the insurer within 48 hours.
• Step 2: Submit valid proof of ID and the policy card. 
• Step 3: Fill the pre-authorisation form from the TPA (Third-Party Administrator- the intermediary that handles claim processing and cashless transactions between the insurer and the hospital).
• Step 4: The insurer will review hospital documents and let you know (by SMS/email) if your cashless claim is approved.

How Do You Get Cashless Treatment in Non-network Hospitals?

Previously, cashless treatment only worked at insurers’ network hospitals. As per IRDAI’s guidelines on Cashless Everywhere in India, you can get cashless treatment at any hospital (even those not in your insurance network).

Consider these points when opting for Cashless Everywhere:

1. Patients should notify their insurer 48 hours before elective surgery (Procedures that patients need but don’t have to be done immediately). 
2. Emergency care patients must notify their insurer within 48 hours.
3. The claim and cashless facility must be admissible under the policy and insurance company criteria.

Insurers are still working to fine-tune the logistics. Hence, you must consider the fine print before choosing a provider to meet your health insurance needs.

Key Takeaways

Cashless health insurance offers a convenient way to manage medical expenses. By understanding how it works, what’s covered, and the new “Cashless Everywhere” initiative, you can make informed decisions to ensure a smoother healthcare experience.

Review your policy terms and exclusions carefully to maximise the benefits of your cashless health insurance plan.