What is Cashless Health Insurance: Types, Benefits & Claim Process

Onsurity Editorial
April 8, 2024
12 min read

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Cashless Health Insurance

Facing unforeseen medical emergencies can impose significant physical, emotional, and financial strains on individuals. To mitigate such burdens, the selection of comprehensive health insurance coverage tailored to individual needs is paramount.

While some insurance policies operate on a reimbursement basis, the cumbersome and protracted nature of this process often prompts individuals to opt for cashless benefit options. These options facilitate access to treatment at network hospitals without upfront payment, thereby alleviating concerns associated with sudden financial arrangements.

Understanding Cashless Claims in Health Insurance

Cashless claims in health insurance involve direct payment from the insurance provider to the hospital for all treatment costs and related medical charges, including hospitalisation fees. This eliminates the need for policyholders to bear out-of-pocket expenses during their medical care journey.

How Does Cashless Health Insurance Work?

The process of availing cashless benefits begins with the policyholder contacting the insurance provider upon hospitalisation. After filing a claim and submitting the necessary documents, the hospital bill is settled directly between the insurer and the hospital.

For planned hospitalisations, notifying the hospital’s TPA desk and the insurance agent ensures a swift and efficient initiation of the cashless process.

Also, Read: A Guide to Health Insurance Claim Process

Key Benefits of Cashless Health Insurance:

Convenience: Immediate access to treatment without the need for arranging upfront funds.

Stress-free, instant benefits: Immediate relief from financial worries, ensuring focused attention on recovery.

Access to superior healthcare: Enables access to the best-in-class medical services without financial strain.

Suggested Read: Types of Health Insurance

Types of Health Insurance Plans Offering Cashless Claim Facility:

1. Individual health insurance policies

Such policies provide coverage to a single person, offering financial protection against medical expenses incurred due to illnesses, accidents, or injuries. With cashless claim facilities, policyholders can access quality healthcare services at network hospitals without the need for upfront payments, ensuring seamless medical care when needed.

2. Family floater plans

These policies extend coverage to the insured family members, including spouse, children, and sometimes parents under a single plan wherein the premium is linked to the oldest member in the group.

Cashless claim facilities under family health insurance plans enable all covered individuals to avail themselves of medical treatment at network hospitals without financial strain, ensuring comprehensive healthcare coverage for the entire family.

3. Senior citizen health insurance policies

Designed specifically for elderly individuals, senior citizen health insurance policies offer coverage tailored to the healthcare needs of older adults. With cashless claim facilities, these policies ensure prompt access to medical treatment without the hassle of upfront payments, addressing the unique healthcare requirements of seniors during their golden years.

4. Women’s policies covering women’s health and childbirth:

Women-specific health insurance policies cater to the unique healthcare needs of women, including coverage for maternity and childbirth-related expenses. With cashless claim facilities, these policies offer seamless access to specialised medical services, ensuring comprehensive care for women’s health issues and a stress-free childbirth experience.

5. Disease-specific health insurance policies

Certain health insurance policies focus on providing coverage for specific illnesses or medical conditions, such as cardiovascular diseases and cancer.

With cashless claim facilities, these specialised policies ensure timely access to advanced treatments and procedures, alleviating the financial burden associated with managing critical illnesses and supporting policyholders in their journey towards recovery.

Crucial Features of Health Insurance with Cashless Benefits

Treatment without financial concerns: Allows individuals to focus on recovery without worrying about medical expenses.

Providing a financial safety net: Offers financial security during unforeseen medical emergencies.

Simple and smooth claim process: Streamlined process for hassle-free settlement of claim.

Pre-approved treatment plans: Expedited approval process for necessary and emergency treatments.

Also, Read: Benefits of Group Health Insurance

Documents Required for Cashless Hospitalisation

When initiating a cashless claim for hospitalisation, it’s essential to gather the necessary documents to streamline the process effectively. Here’s a breakdown of the required documentation:

1. Policy copy or insurance card

This document serves as proof of your health insurance coverage. Whether in the form of a physical copy or an electronic card, it contains vital information such as your policy number, coverage details, and contact information for your insurance provider.

2. Valid government ID

A government-issued identification document, such as a passport, driver’s license, Aadhar card, or voter ID, is essential for identity verification purposes during hospitalisation.

3. Doctor’s prescription

A prescription from a qualified medical practitioner recommending hospitalisation is necessary to validate the need for medical care and treatment.

4. Cashless health card (if provided)

Some insurance providers issue cashless health cards to their policyholders, facilitating seamless cashless transactions at network hospitals. This card contains relevant details and may expedite the verification process.

5. Pre-authorized hospital forms

These forms, provided by your insurance company, require completion and signature by the attending physician. They help confirm the medical necessity of hospitalisation and authorize cashless benefits.

6. Medical history and reports

Any relevant medical records, test results, or treatment history pertaining to your current health condition should be readily available. These documents aid in understanding your medical background and guide treatment decisions.

7. Hospital admission form

Provided by the hospital during admission, this form captures essential details about your hospital stay, treatment preferences, and contact information.

8. Claim forms

Specific forms provided by your insurance company are necessary to initiate the cashless claim process. These forms detail the medical services received and facilitate communication between the hospital and the insurer.

9. Nominee contact details

10. Additional paperwork

Depending on the requirements of the hospital and your insurance provider, you may need to furnish additional documentation. This could include consent forms, referral letters, or any other documents specific to your treatment or policy terms.

By ensuring you have these documents prepared and readily available, you can expedite the cashless claim process and focus on receiving the necessary medical care without unnecessary delays or complications.

Also, Read: Private Vs Public Hospitalisation Costs in India

Filing a Cashless Health Insurance Claim

Here’s how the process unfolds for both planned and emergency hospitalisations:

Cashless Claim During Planned Hospitalisation

Hospital submits the bill to the insurer: Upon admission, the hospital forwards the treatment and expense details to the insurance company for review and approval.

Insurer settles the bill directly with the hospital: Once the claim is processed and approved, the insurer directly pays the hospital for the medical services rendered, eliminating the need for the insured individual to make upfront payments.

Ensures a stress-free payment process during hospitalisation: With the insurer handling the billing directly, policyholders can focus on their recovery without the added worry of managing financial transactions, creating a seamless and stress-free hospitalisation experience.

Cashless Claim During Emergency Hospitalisation

Patient is admitted to a network hospital: In the event of an emergency, the insured individual seeks treatment at a network hospital affiliated with their insurance provider, ensuring access to immediate medical care.

TPA desk co-ordinates with the hospital for bill settlement: The TPA desk (Third-Party Administrator) at the hospital collaborates with the insurance company to facilitate the cashless claim process. They verify the policy coverage and coordinate with the hospital to streamline bill settlement procedures.

The insurance company authorises and pays the hospital based on policy coverage: Once the necessary approvals are obtained, the insurance company authorises payment for the medical expenses incurred during the emergency hospitalisation. The insurer directly settles the bill with the hospital, ensuring the insured individual receives prompt and uninterrupted medical care without bearing the financial burden upfront.

Also, Read: Health Insurance with OPD Cover

Reasons for Claim Rejection in Cashless Health Insurance:

Understanding the reasons for claim rejection in cashless health insurance is crucial for policyholders to ensure their claims are processed smoothly.

Here’s a deep dive into each potential reason:

1.Undisclosed pre-existing medical conditions:

Failure to disclose pre-existing medical conditions at the time of purchasing the insurance policy can lead to claim rejection. Insurers rely on accurate medical history to assess risk and determine coverage eligibility. Concealing such information may result in claims being denied.

2.Insufficient documentation:

Inadequate or missing documentation can hinder the claim verification process. Policyholders must provide complete and accurate medical records, bills, prescriptions, and other relevant documents to support their claim. Without proper documentation, insurers may reject the claim due to lack of evidence.

3.Violation of waiting period:

Insurance policies often have waiting periods for certain conditions or treatments, during which claims related to those specific conditions may be rejected. Filing a claim for treatment before the waiting period expires violates policy terms and can result in claim denial or rejection.

4.Lapsed insurance:

Failure to pay insurance premiums or subscription fee on time leads to policy lapse, rendering the coverage inactive. Claims made during the period of lapsed insurance are typically rejected as the policy is not in force. It’s essential for policyholders to keep their premiums up to date to maintain continuous coverage.

5.Policy exclusions:

Insurance policies often have specific exclusions, such as non-medical treatments, cosmetic surgeries, or certain pre-existing conditions. Claims for services or conditions not covered by the policy are likely to be rejected. Policyholders should thoroughly review their policy documents to understand coverage limitations and exclusions in health insurance.

6.Unjustified procedures or treatments:

Insurers assess the necessity and reasonableness of medical procedures and treatments claimed by policyholders. If a procedure or treatment is deemed unnecessary or not supported by medical evidence, the claim may be rejected.

Policyholders must ensure that the treatments they receive are medically justified and comply with policy terms.

Related Read: Group Health Insurance for Employees

Inclusions and Exclusions in Cashless Health Insurance

Understanding the coverage and exclusions in cashless health insurance policies is essential for policyholders to grasp the extent of their benefits and limitations.

Inclusions in Cashless Health Insurance

1.Hospitalisation Fees:

Understanding the coverage and exclusions in cashless health insurance policies is essential for policyholders to grasp the extent of their benefits and limitations.

2.Doctors fees

Fees charged by medical practitioners, surgeons, specialists, and consultants during hospitalisation or outpatient visits are covered under cashless health insurance.

3.Medications:

Expenses incurred for prescribed medications and drugs administered during hospitalisation or as part of out–patient treatment are usually covered, ensuring access to necessary pharmaceuticals without additional financial burden.

4.Ambulance services:

Emergency ambulance services required for transporting the insured to the hospital in case of accidents or critical medical conditions are often covered under cashless health insurance policies.

5.Pre and post-hospitalisation expenses:

Cashless health insurance may extend coverage to expenses incurred before and after hospitalisation, such as diagnostic tests, consultations, and follow-up visits, ensuring comprehensive medical care.

6.Day procedures:

Certain medical procedures that do not require overnight hospitalisation, such as minor surgeries or diagnostic procedures, may be covered under cashless health insurance for day care treatment.

Exclusions in Cashless Health Insurance

1.Dental treatments:

Routine dental procedures, including dental check-ups, fillings, and extractions, are typically excluded from cashless health insurance coverage. Dental treatments often require separate dental insurance coverage.

2.Congenital defects

Medical conditions or birth defects present at birth, such as congenital heart defects or cleft palate, are generally excluded from cashless health insurance coverage.

3.Venereal diseases:

Sexually transmitted infections or diseases, such as HIV/AIDS, syphilis, and gonorrhoea, are typically excluded from coverage under cashless health insurance policies.

4.Self-inflicted injuries:

Injuries resulting from intentional self-harm or suicide attempts are usually not covered under cashless health insurance, as they are considered non-accidental and intentional acts.

5.AIDS:

Acquired Immunodeficiency Syndrome (AIDS) and related conditions are commonly excluded from coverage under cashless health insurance due to their chronic and costly nature.

6.Infertility treatments:

Procedures or treatments aimed at addressing infertility issues, such as in-vitro fertilisation (IVF) or assisted reproductive technologies, are often excluded from cashless health insurance coverage.

7.Cosmetic surgeries:

Elective or cosmetic surgeries performed for aesthetic purposes, such as rhinoplasty or breast augmentation, are typically not covered under cashless health insurance unless deemed medically necessary for reconstructive purposes.

8.Pre-existing illnesses:

Medical conditions or illnesses that exist prior to the commencement of the insurance policy are generally excluded from coverage for a specified waiting period.

9.Certain alternative treatments:

Alternative therapies or treatments, such as acupuncture, chiropractic care, or naturopathy, may be excluded from cashless health insurance coverage unless specifically included as part of a comprehensive health plan.

Also, Read: Difference Between Life Insurance and Health Insurance

Difference Between Cashless and Reimbursement Claims:

Aspect	Cashless Claims	Reimbursement Claims
Meaning	Hospital bills are directly settled by the insurance company; policyholders do not make upfront payments.	Policyholders pay hospital bills initially and later seek reimbursement from the insurance company.
Payment	The insurer pays the hospital directly.	The policyholder pays the hospital and is later reimbursed by the insurer.
Approval Process	Approval is required before hospitalisation or during admission; pre-authorisation is often necessary.	Policyholders cover medical expenses initially and submit documents for approval after treatment.
Documentation	Policy card, ID proof, pre-authorisation forms, medical history, and admission forms.	Invoices, medical reports, prescriptions, claim forms, policy documents, and discharge summaries.
Time Taken	Typically, faster processing as pre-authorisation streamlines the process, and immediate payment to hospitals.	Longer processing time due to the need for document submission, verification, and reimbursement approval.

Things to Consider While Opting for a Cashless Health Insurance Policy:

When purchasing a cashless health insurance policy, consider the following aspects to ensure comprehensive coverage tailored to your needs:

1.Benefits and coverage:

Ensure the policy covers essential aspects such as doctors’ fees, hospitalisation expenses, critical illness coverage, and medication costs. Opt for broader coverage to enhance your protection against various medical expenses.

2.Claim process:

Understand the entire claim process before purchasing the policy. Look for insurers offering hassle-free and quick claim settlement procedures. Choose policies with straightforward claim processes to ease your experience during medical emergencies.

3.Network hospitals:

Inquire about the insurer’s network hospitals that offer cashless treatment. Opting for insurers with a wide network of hospitals ensures faster and convenient claim processing, as you can avail cashless treatment at these network hospitals without upfront payments.

4.Premium and costs:

Compare premiums and costs of similar policies from multiple insurers. Select a policy that aligns with your budget while providing comprehensive coverage suitable for your health conditions and requirements.

4.Age limits for renewal:

Determine the maximum age for policy renewal and choose policies offering lifelong renewal benefits. Opting for policies with no age limit for renewal ensures uninterrupted health coverage, especially during advanced age.

5.Policy omissions:

Recognise any exclusions or limitations in coverage. Be aware of the types of health conditions or treatments that may not be covered under the policy to avoid surprises during claims.

7.Coverage for pre-existing conditions:

Check if the policy provides coverage for pre-existing health conditions. Verify with the insurer regarding coverage for any existing medical issues you may have to ensure adequate protection.

8.Riders and extras:

Explore additional riders or add-ons offered by the insurer to enhance your policy coverage. Consider adding riders that align with your specific healthcare needs, providing additional benefits beyond the basic policy coverage. Evaluate the suitability of riders based on your requirements and preferences.

Quick Read: Domiciliary Hospitalisation

Why Onsurity Is Your Perfect Partner

Experience hassle-free cashless health insurance claims with your Onsurity membership. Here’s how:

Comprehensive coverage: Enjoy coverage for both individual and group needs through our partner insurers. With access to over 7000 partner hospitals, you can avail of cashless claims effortlessly.

Convenient claim process: Our app streamlines the claim process, making it easy and efficient. Built-in claim support ensures a smooth experience from start to finish.

Find network hospitals easily: Use the Onsurity App to locate the nearest network hospital with just a few taps. Simply access the ‘cashless hospital’ feature on the homepage and enter your PIN code.

Expert support available: Need assistance with the claim process or have queries? Reach out to our dedicated Good Doctors Team for prompt assistance and guidance every step of the way.

At Onsurity, we provide affordable employee healthcare solutions tailored for SMEs and startups. Our memberships offer access to teleconsultations, health check-ups, and medication delivery, ensuring flexible, economical, and practical health benefits for your workforce.

Cashless health insurance not only adds value but also reduces the stress of financial worries during medical emergencies. With Onsurity’s cashless claim benefit, you can receive timely and quality treatment for all your medical needs. Learn more about cashless claims with Onsurity to make the most of your health coverage!

In conclusion, Onsurity empowers you to prioritise your health with seamless cashless health insurance claims, ensuring peace of mind and comprehensive medical coverage when you need it most.

FAQs:

1. What is cashless in health insurance?

Cashless in health insurance allows policyholders to avail medical treatments without making direct payments to the medical facility or hospital.

2.Which is the best cashless health insurance in India?

The best cashless health insurance varies based on individual requirements and preferences. It’s essential to choose a policy that aligns with your specific healthcare needs.

3. How do I claim non-cashless health insurance?

To claim non-cashless or reimbursement benefits, you need to submit invoices, including prescriptions, medical bills, test reports, and other relevant documents. The documentation requirements may vary depending on the type of claim.

4.What is the difference between cashless and reimbursement?

In cashless claims, the insurance provider directly settles the medical bills with the hospital, eliminating the need for upfront payments. In reimbursement claims, policyholders pay the hospital and later seek reimbursement from the insurance provider.

5.How does a cashless insurance claim work?

In a cashless claim, the insurance provider and hospital coordinate to settle the bill based on the policy coverage. Policyholders receive medical treatment without the need for upfront payments.

6.Which health insurance is best for cashless treatment?

The suitability of health insurance for cashless treatment depends on the policy coverage. Choose a policy that offers comprehensive coverage aligned with your healthcare needs.

7. What is not covered in cashless health insurance?

Cashless health insurance typically does not cover medical expenses incurred within 30 days from the policy start date, except in the case of accidents. Expenses related to the misuse of drugs or alcohol are also generally not covered.

8.What is a cashless policy in insurance?

A cashless policy in insurance facilitates direct settlement of medical expenses and hospitalisation between the hospital and the insurance provider, without the need for policyholders to make upfront payments.

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