Healing Illnesses With Ease

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Healing Illnesses With Ease
Himali Patel - 08 September 2019

Life is so unpredictable at times.

One minute everything is going exactly as planned and then out of the blue, your whole world crashes down. All it takes is a flick of a button and your world turns upside down. All of us have been through such times, especially  when a medical emergency strikes out of nowhere.

And arranging funds on an immediate basis during medical emergencies can be a difficult task. Whether it is rushing to the ATMs or calling up friends and family in such a dire situation for financial help, can be immensely stressful. However, cashless mediclaim can come to the rescue. A mediclaim insurance policy can help you get treated at any hospital without breaking your head over it.

The expenses raised during the hospitalisation are directly paid by the insurance company to the hospital. Commenting on the benefit of cashless mediclaim, Anurag Rastogi, Member of Executive Management, HDFC ERGO General Insurance said, “Cashless mediclaim is designed to help reduce the financial burden on policyholder in case of a health emergency. Expenses incurred in the policyholder’s treatment is paid by the insurer directly to the hospital if the patient is admitted to a network hospital.”

Currently, two types of claim processes are available in the market – cashless and reimbursement. While under a cashless mediclaim bills are directly settled by the insurance company at a network hospital, in case of reimbursement policy, one needs to pay all the expenses oneself first and then the insurance company reimburses the same. In case of a reimbursement policy, “the insured has to pay all her medical bills and other costs involved in hospitalisation and treatment and then claim reimbursement. In order to avail reimbursement claim one has to provide necessary documents including original bills to the insurance provider,” said Prasun Sikdar, MD and CEO, Cigna TTK Health Insurance.

Under cashless mediclaim policy, the policyholder can get treated without paying at the hospital directly. And this facility is available across all network hospitals empaneled with the insurance company. Needless to say, it’s a great feature, which ensures that one does not burn a hole in his or her pocket. Sharing his ideas on the benefit of cashless mediclaim, Ravichandran N, Executive Vice President and CTO, Kotak Mahindra General Insurance said, “When you avail cashless mediclaim, all medical expenses are covered by the insurance company as per the  terms and condition, eliminating the need for policyholder to pay upfront from his or her pocket.”

So how does a cashless mediclaim policy work? It ideally works in two scenarios when an insured gets admitted in a hospital.  One is a  pre-planned hospitalisation and another emergency hospitalisation. When it comes to pre-planned hospitalisation, the insured can avail treatment at a network hospital involving either a surgery or any medical therapies. In pre-planned hospitalisation cases, the policyholder needs to approach the insurance company or the Third-Party Administrator (TPA) appointed by the company.

Now, the TPA acts as an intermediary between the policyholder and the insurer and helps settle claims. The insured can also approach the TPA desk, which is present in every hospital who usually prepares the  documents and sends them to the  company for pre-authorisation of cost of treatment.

“In case a customer approaches the insurance company directly, then he needs to provide all the details and reports pertaining to the treatment along with details of health provider with costs of treatment. Thereafter, once the insurance company provides a pre-authorisation letter to the insured and TPA desk, if the claim is admissible as per the terms and  conditions of the policy,” added  Nikhil Apte, Chief Product Officer, Royal Sundaram General Insurance.

However, under emergency hospitalisation, the policyholder will have to contact the TPA of network hospital within 24-hours of admission along with detailed report  and cost of treatment.  Once you are hospitalised all you need to do is show is your medical insurance card to the hospital authorities. You can also approach the customer service of the insurer or the TPA helpdesk stationed at the network hospital. Also, in case of any change in the line of treatment, the insurance desk at the hospital reaches out to the TPA or the insurance company for further approval of additional costs.

When it comes to selecting between cashless or reimbursement, one should keep in a mind that, under a cashless claim, customer contribution is nil or minimal. Whereas in case of a reimbursement claim customer has to settle the entire hospital dues upfront and then apply for settlement. Experts say that the turn-around-time (TAT) is the main difference for settlement process. Commenting on the TAT, Apte explained,

“Cashless claims are settled much faster as the insurance company can validate the claim and it is more authentic since the customer is admitted in a network hospital and details can be verified. The TAT in case of a reimbursement claim is much longer  as there are higher chances of frauds in spite of perfect documentation. Hence companies need to investigate such claims at times.”

It is important to note, that one can avail the cashless facility only at selected network hospitals. This might also limit the choice of hospitals for the insured. In case if you choose to  go for a hospital, which is not in the network, reimbursement is the way out. Also, when it comes to expenses, not all expenses are covered in the hospital under the cashless scheme. Charges such as registration fees, visitor’s fees, document charges, cost of medicine and toiletries amongst other are not covered.  In most circumstances,  an insurer pays only a part of the sum required for the treatment. Usually,  the policy covers only expenses incurred for the treatment. Availing cashless Mediclaim now-a-days has become much easier and faster than before.

Going forward it is expected that cashless facility can be availed in a split of second with the help of technology. “Technology is going to play an important role in settlement of claims. Second, with the initiative of regulator and insurance companies, many  network hospitals are expected to have NABH accreditation, which will benefit the policy holder in getting quality healthcare,” explained  Ravichandran N. Considering the rising costs of healthcare, India  has a good prospect in the  coming years, when it comes to opportunities’ in health saving  and outpatient department.

However, how do you go about choosing the right cashless mediclaim policy? Numerous mediclaim policies are available in the market and surprisingly most policies are almost similar. Therefore, check the benefits that are unique. You can start by comparing the basic features. Normally, all health insurance policies cove hospitalisation charges post approval from the TPA. But you can always look out for extra benefits offered in the policy such as daily cash benefits or availability of domiciliary treatment.

On the other hand, one can say that cashless insurance works by providing treatment at any of the listed network hospitals. You might be impressed to learn that a certain health insurance plan includes some top hospitals in its network. However, to find a plan suitable for you, focus on the proximity of these hospitals as well. In case of an emergency, you would only want to be rushed to the nearest hospital.

An ideal insurance plan would be the one, which has a large number of network hospitals. You know you are safe when you have multiple choices and moreover, these options come at no extra cost. Needless to say, they reduce too much stress during critical situation.

However, with increasing awareness around health, it is not about hospitalisation expenses and out-patient bills any more. “We need to re-define ‘health’ in ‘health insurance’ and look it from customers’ lens and make it more relevant. We have to make sure that the products we sell and the technology we use, is in line with this shift in customer need and customer behaviour. Sandbox in insurance is the big booster that is going to change the way insurance is in India,” said Sikdar. With that, now-a-days insurers are constantly innovating and exploring new ways in, which claims processes are made smoother and simpler for policyholders. And in that case cashless hospitalisation is surely a stress-free way of availing hospitalisation benefits for those who have limited cash reserve.


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