Cashless Mediclaim

Cashless Mediclaim- Overview

In the cashless mediclaim policies the holders can get themselves treated at a hospital or a nursing home that is part of the service provider's network and they do not need to make any payments whatsoever.

The insurance company takes care of these matters through their representatives who are referred to as third party administrators (TPAs). The major benefit of cashless mediclaim is that the insurers need not worry about financial matters during emergency situations.

Types of Cashless Mediclaim

In these policies, the payment is normally done till the amount of sum insured is covered. There are two major types of cashless mediclaim - planned and emergency. In case of planned hospitalization the policy owner is aware that he or she will be spending the next few days in hospital.

In case of an emergency hospitalization, which can be either due to a serious and deteriorating condition or accident or both, the requirement is immediate.

Cashless Mediclaim - Points to Remember

The following points need to be kept in mind while availing a cashless mediclaim policy:

• The TPA needs to be informed before the insured is admitted to a hospital or for emergencies. This can be done by any family member as well
• The investigation should be done properly and medical reports should be produced likewise
• The insured should have an ID card so that it can be produced as a proof of hospitalization
• The health insurer should be informed in the manner that is prescribed by the concerned company
• When the policy is being renewed the insured and other responsible people around him or her should go through the list of hospitals and nursing homes in the network and pick out ones that are most suitable
• Should store important details like policy number, TPA help desk numbers, and cashless card number in their own mobile phones as well as ones belonging to family members
• Carry sufficient cash in case of emergency requirements
• In addition to the above mentioned factors, the policyholders need to remember that their admission to a network hospital shall be subject to the availability of bed and further terms and conditions will apply in these cases.

Cashless Mediclaim Disadvantages

The cashless mediclaim policies normally have the following disadvantages:

• Do not cover registration costs
• Do not cover non medical expenses
• TPAs might not approve of hospital charges under "reasonable and customary charges" clauses
• Claims are approved on the basis of average costs
• Claims may be rejected if the TPA is not satisfied with the clients' or hospitals' credibility

How to make claims in cashless mediclaim policies?

The policyholder should also have proper and total knowledge of the claims conditions and terms so that their claims are successful. The insurers normally decide on including the hospitals in their network after analyzing their standard and negotiating on the charges.

While admitting the patient the claimants need to mention at either the insurance desk or admission desk of the hospital that they are in a particular network that is supposed to have included the said hospital or nursing home. They are then called on to fill up a pre-authorization form and to get it signed by concerned officials.

Cashless mediclaim claims procedures

The hospital then faxes the form for the consent of insurer or TPA's cashless team. When the fax is sent the team reviews it and then takes the decision as per the coverage terms and agreements.

If the claims are agreed to then the cashless team sends an authorization note via fax - this note spells out the initially authorized amount. This is basically the amount that the team will be paying to the hospital.

When the patient is being discharged the hospital will send one more request for authorization along with the final bill. This too will be dealt with as per the policy terms and conditions. The customers may need to pay any amount that is not paid by the insurer or the TPA.

In case of emergency situations the time taken to process is 6 hours. However, the claimant needs to be in touch with the TPA to know the state of the claim. It is considered ideal to buy such policies through health insurance advisors, brokers, or agents as they help to coordinate the claims process properly.

If it is a planned hospitalization then the claimants should inform the TPA beforehand and make sure that the cashless formalities are done with, preferably before the insured gets admitted.

Cashless mediclaim policies - when can claims be rejected?

The claims may be rejected if the information provided in the pre-authorization form is not enough for the request to be approved. In most of the cases, the TPAs ask the hospitals for additional information in case the requirement arises. If the insured has already finished the sum assured for a particular year his or her claims may be rejected.

The TPA may not approve the bill straightaway - in such cases the insured need to spend the bill on their own and then get the compensation later on.

Cashless Mediclaim Policies in India

National Insurance Cashless Mediclaim Policies

Mediclaim Policy

The policy provides coverage for the following reasons of hospitalization:

• Illness
• Disease
• Accident
• Surgeries

The premium of this policy includes cashless facility that can be provided through the TPAs. In case the policyholder wishes not to avail the cashless facility they can get a 6% discount on their premium.

The policy provides coverage for all hospitalization expenses that have resulted in a fair manner and include the following:

• Boarding and room expenses as allotted by the nursing home or hospital
• Fees of surgeons, consultants, anesthetists, specialists, and medical practitioners
• Nursing expenditure
• Expenses of anesthesia, x-rays, blood supplies, dialysis, oxygen supplies, chemotherapy sessions, operation theatre, radiotherapy sessions, surgical appliances, pacemaker, medicines and drugs, artificial limbs, diagnostic materials, and organs

VIDYARTHI - Mediclaim for Students

The VIDYARTHI - Mediclaim for Students program provides cashless facilities through TPAs. The minimum premium of this program is INR 582. The program covers the following costs:

• Boarding and room expenses
• Fees of surgeons, consultants, anesthetists, specialists, and medical practitioners
• Nursing expenditure
• Expenses of anesthesia, x-rays, blood supplies, dialysis, oxygen supplies, chemotherapy sessions, operation theatre, radiotherapy sessions, surgical appliances, pacemaker, medicines and drugs, artificial limbs, diagnostic materials, implants and stents, and organs

VARISTHA - Mediclaim for Senior Citizens

The VARISTHA-Mediclaim for Senior Citizens plan provides coverage of hospitalization expenses of the insured through the cashless facility. The program covers the following:

• Boarding and room expenses
• Fees of surgeons, consultants, anesthetists, specialists, and medical practitioners
• Expenses of anesthesia, x-rays, blood supplies, dialysis, oxygen supplies, chemotherapy sessions, operation theatre, radiotherapy sessions, surgical appliances, pacemaker, medicines and drugs, artificial limbs, diagnostic materials, implants and stents, and organs

The minimum premium of this program is INR 6187.

New India Assurance Cashless Mediclaim Policies

The following policies of New India Assurance provide cashless facilities: Mediclaim 2007 Policy

The Mediclaim 2007 Policy offers cashless facilities through the TPAs. The policy covers the following:

• Day care treatment
• Pre existing diseases
• Ambulance expenses
• Pre existing conditions such as diabetes and hypertension
• Ayurvedic, Unani, and homeopathic medicine systems

Family Floater Mediclaim Policy

The Family Floater Mediclaim Policy covers the following:

• Day care treatment
• Pre existing diseases
• Ambulance expenses
• Pre existing conditions such as diabetes and hypertension
• Ayurvedic, Unani, and homeopathic medicine systems
• Post and pre hospitalization costs

Janata Mediclaim Policy

The Janata Mediclaim Policy provides coverage for the following:

• Day care treatment
• Pre existing diseases
• Ambulance expenses
• Pre existing conditions such as diabetes and hypertension
• Ayurvedic, Unani, and homeopathic medicine systems

The minimum premium for this program is INR 750.

Senior Citizens Mediclaim Policy

The Senior Citizens Mediclaim Policy offers coverage for the following:

• Day care treatment
• Pre hospitalization expenses
• Ambulance expenses
• Post hospitalization costs
• Ayurvedic, Unani, and homeopathic medicine systems

The minimum premium of this plan is INR 3850.

Oriental Insurance

The plans of Oriental Insurance that provide cashless benefits may be described below:

Individual Mediclaim Health Insurance

The Individual Mediclaim Health Insurance plan covers the following:

• Hospitalization costs
• Medical expenses for surgeries and diseases that are covered in the plan
• Pre hospitalization costs
• Post hospitalization costs

Overseas Mediclaim - Business and Holiday

The Overseas Mediclaim - Business and Holiday policy covers the following:

• Services of physicians
• Repatriation of remains in case of death
• Hospital services
• Personal accident
• Medical services
• Loss of checked baggage
• Emergency medical transportation done locally
• Delay of checked baggage
• Dental services
• Loss of passport
• Emergency medical evacuation costs - however, it needs to have been ordered by a physician
• Personal liability
• Medical evacuation expenditure

Overseas Mediclaim - Employment and Study

The Overseas Mediclaim - Employment and Study program provides coverage for the following:

• Medical expenses and repatriation
• Delay of checked baggage
• Personal accident
• Loss of passport
• Loss of checked baggage
• Personal liability

Last Updated on 09/19/2012

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