All you need to know about cashless mediclaim policy in India

All you need to know about cashless mediclaim policy in India

Having an adequate health cover is an essential requirement of today. Considering the rapid rise in lifestyle diseases, road accidents and inflated cost of healthcare, mediclaim is one of the most important investments one has to make. An unfortunate accident or a sudden illness can lead to huge amount of out-of-pocket medical expenses without having the right cashless mediclaim insurance policy. With the rising rate of healthcare inflation, treatment cost for minor illness can also deplete your savings and become a financial burden. Due to this rising concerns of treatment cost, many insurers are now offering mediclaim policies with cashless facility.

Overview of cashless mediclaim policy

Cashless mediclaim policy is an excellent solution to protect yourself against sky-rocketing medical expenses in the event of hospitalisation for an illness or due to an accident, without having to incur any out-of-pocket expenses. Basically, insurance companies are tied up with various hospitals across the country for the cashless facility which are referred to as ‘network hospitals’. On availing treatment at any of the network hospitals, medical bills will be directly settled to the hospital by insurance company. ‘Cashless mediclaim policy’ comes as a blessing in the event of medical emergencies by ensuring you complete financial security and peace of mind. When compared to reimbursement mediclaim policies where you pay medical bills first and then get them reimbursed from insurance company, cashless mediclaim is extremely beneficial in the time of need.

Types of cashless mediclaim policies in India:

You can safeguard your financial well-being and your health by investing in various types of cashless mediclaim policies available in India. Indian insurance market offers various types of mediclaim policies depending on the need of people. Following are the major types of cashless mediclaim policies available in India:

1. Individual cashless mediclaim policy:Under individual cashless mediclaim policy, an individual is provided a specific amount of medical coverage for a specified period of time. The coverage offered can be claimed for hospitalisation expenses whenever the insured individual is in need of it.
2. Family floater cashless mediclaim policy:Under Family floater cashless mediclaim policy, all members of the family are covered under a single policy with one fixed sum insured. The policy generally covers self, spouse and dependent children. Many policies even cover dependent parents and parents-in-law. The coverage provided under the policy can be utilised by any insured member of the family during the policy period for hospitalisation expenses.
3. Senior citizen cashless mediclaim policy: Unique healthcare needs of old age people are covered under senior citizen cashless mediclaim policy. These policies are carefully crafted to take care of senior citizen’s hospitalisation expenses in the crucial stage of their life.

How to avail cashless mediclaim (planned /emergency)?

With the cashless facility offered by mediclaim policies, you don’t need to run around arranging for the funds in the time of medical emergencies. You can locate the nearest network hospital of your insurance company and avail the cashless mediclaim facility without having to incur any out-of-pocket cost, wherein insurer directly makes the payment of medical bills to the hospital.

Third party administrator (TPA) coordinates between hospital and the insurance company in the process of cashless mediclaim settlement. There will be insurance desk set up in every network hospital to help initiate the cashless claims. Cashless mediclaim services can be availed in two ways during hospitalisation:

Cashless claims for planned hospitalisation:

In the case of planned hospitalisation, you will have good enough time to choose your preferred hospital out of list of your insurer’s network hospitals for availing treatment. Following is the simple process to follow for availing cashless treatment in case of planned hospitalisation:

1. Choose the network hospital by referring to your insurance company’s website for list of network hospitals or by calling up your insurer’s customer care
2. Once you choose the hospital for your treatment, contact the hospital’s insurance desk and fill-up pre-authorisation cashless request form which can be downloaded online on TPA website or physical copy can be obtained from insurance desk at the hospital
3. Submit the pre-authorisation cashless request within the time limit specified by your insurance company. Details filled in the request form will be verified and signed by the hospital authorities
4. TPA/insurance desk will check the eligibility and authenticity of pre-authorisation cashless request submitted by you
5. Upon verifying the request, TPA will either approve or reject the request placed
6. Sanction letter will be issued to the hospital mentioning the amount approved
7. On producing the final documents by hospital, payment of claim will be directly made to the hospital

Cashless claims for emergency hospitalisation :

In the case of a medical emergency that requires immediate medical care, cashless claim can be initiated after getting admitted at the nearest network hospital. Following is the simple process to follow for availing cashless treatment in case of emergency hospitalisation:

1. Upon getting admitted at the nearest network hospital, show your policy document/card to the hospital. The document will contain necessary details like policy number, policy type and name of the insurance company etc.
2. Contact insurance desk of the hospital and fill up pre-authorisation request form within 24 hours of hospitalisation
3. Third party administrator/insurance company will review you pre-authorisation request and other documents submitted
4. Once documents are verified, TPA will either approve or reject your cashless claim request. If the claim is approved, cashless treatment can be availed
5. Once final set documents submitted by hospital are verified, claim amount will be directly settled with the network hospital

Reasons for claim rejection in cashless mediclaim policy:

Cashless insurance claims also can get rejected for various reasons. However, some of them can be avoided with a little care. Let’s take a look at the reasons for rejection of cashless claims.

1. Unawareness of claim process:
   Sometimes not being aware of the claim process and not following the process diligently can lead to rejection of claims. For example, not following the time limit for placing the claim may become a reason for rejection. Filling up the wrong information in the form, not submitting the right documents etc. could lead to rejection of cashless claims. Knowing the claim process properly and taking help of insurance company’s customer support team for the information can help reduce such type of claim rejections.
2. Pre-existing conditions:
   Pre-existing health conditions is one of the top reasons for rejection of cashless claims. Some of the pre-existing health conditions at the time of the policy are not covered under the cashless mediclaim policies temporarily for a certain period of time, which may vary from 24 months to 48 months. During this waiting period, expenses incurred for treatment of pre-existing illnesses are not covered by cashless mediclaim policies. Placing the claim for pre-existing medical conditions during the waiting period is one of the reasons for rejection of cashless claims.
3. Non-disclosure of information:
   Holding back the information at the time of buying cashless mediclaim policy is one of the main reasons for claim rejections later. For example, not disclosing the details about a pre-existing health condition while purchasing the cashless mediclaim policy can become reason for claim rejection later.
4. Exclusions:
   Though cashless mediclaim policies cover all the major hospitalisation expenses, policies do come with certain exclusions. For example, treatment expenses incurred for hospitalisation relating to sexually transmitted diseases, AIDS/HIV are not covered under cashless mediclaim policies. Claims cannot be raised for expenses that are permanently excluded from the policy. Claims raised for exclusions will lead to rejection of claims.
5. Policy period:
   Cashless mediclaim policies are insurance contract for a specific period of time called policy period. Once the policy expires, coverage provided under the specific policy stands invalid. Any claim that is raised after the expiry of the policy period and before the renewal leads to rejection of claims.

Points to remember before buying cashless mediclaim policy:

Buying the ideal cashless mediclaim policy is a daunting task considering the huge variety of plans available in the market. To make a rational purchase, there are certain important points that you need to consider. Following are the important points to consider at the time of buying cashless mediclaim policy:

1. Right coverage:
   Remember to choose the right amount of coverage for your cashless mediclaim policy keeping in mind the healthcare inflation. Having an adequate amount of coverage provides complete protection.
2. Network hospitals:
   Ensuring your preferred hospitals are there in the list of your insurer’s network hospitals is really important to avail the timely cashless treatment. It’s good to go with insurance companies having wider network of hospitals. Wider network helps in getting timely medical care, quality treatment along with making it all the more convenient for you.
3. Waiting period:
   Almost every cashless mediclaim policy comes with certain waiting period for treatment of pre-existing illnesses and for certain specific treatments and illnesses. During the waiting period you cannot make any claims for the treatment of such illnesses or medical conditions. It’s ideal to choose the policies that come with lesser waiting period. However, this may depend on your healthcare requirements and present health conditions.
4. Renewability:
   Considering the difficulty in getting the mediclaim policies with increasing age, it’s always better to go with policies that offer lifelong renewability. Such policies can be renewed for lifetime without compromising on the coverage.
5. Value adds:
   Though cashless mediclaim policies are primarily meant for covering hospitalisation expenses during illnesses and accidents, you can expect certain additional benefits under the policy such as free medical check-ups and maternity benefits etc. Depending on your requirement, avail policy with some value adds.
6. Incurred claim ratio:
   Ratio of claims settled by the insurance company is an important consideration at the time of buying cashless mediclaim policy. Insurance company with high claim settlement ratio ensures that your claims are settled quickly and conveniently without any hassles.
7. Cost:
   Though buying decision cannot just be based on cost of cashless mediclaim policy, exorbitant premiums may hit your yearly budget. Hence, consider plans that can provide you much needed coverage within your affordability range.

Cashless mediclaim policy is an amazing solution to safeguard your financial well-being in the event of medical emergencies. Cashless facility helps you avail quality medical treatment at the right time. You can buy cashless mediclaim policy on Turtlemint by comparing various plans side by side based on various parameters and choose the right one for you.

Frequently Asked Questions (FAQ’s)

What are the factors that affect cashless mediclaim policy’s premium?

Mediclaim insurance premiums are determined based on numerous factors. Following are some of the important factors that affect your cashless mediclaim policy’s premium:

• Age
• Pre-existing medical conditions
• Habits such as alcohol and drug abuse
• Family health history
• Profession
• Marital status, etc.

What is ‘free look period’ in cashless mediclaim policy?

Free look period in cashless mediclaim policy refers to time given to new policyholders to understand the terms and conditions of the policy and terminate the policy without penalties, in case he/she is not satisfied with the terms and conditions of the policy. Usually, most of the cashless mediclaim policies come with 15 days free look period within which policy can be cancelled without penalties. However, it’s important to state the reason for cancellation.

What are the tax benefits of cashless mediclaim policy?

Premiums paid towards cashless mediclaim plans can be claimed as a tax deduction under Section 80D of the Income Tax Act, 1961. Tax deduction can be availed on premiums paid towards health insurance plans taken for self, spouse, children and parents.

Following are the details –

Can I have more than one cashless mediclaim policy?

Yes. You can have more than one cashless mediclaim policy.

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Courtesy Article:  Ankita Sejpal / September 30, 2019