Cashless settlement in Medical Treatment

Negotiated Settlement

When your surgery or hospitalization is planned, you are required to inform the insurance company or its third party administrator at least 48 hours * (Depends on the company) before you get admitted. In case of an emergency, this should be done within 24 hours of hospitalization.

One of the most important aspects of choosing a medical cover is not having to pay from your pocket for the hospital treatment. Cashless settlement, as it is called, is an aspect you must be aware of with respect to your medical insurance policy.

PLANNED HOSPITALISATION

When you have discussed with your doctor and have a scheduled medical procedure or hospitalization  there would be sufficient time to take care of all procedures.

Under such circumstances, you are required to inform the insurance company or its third party administrator (TPA) about the surgery or planned hospitalisation at least 48 hours before you get admitted. This way, your cashless settlement could work without any hitch.

In case of an emergency, you or your family members or friends must inform the TPA within 24 hours of hospitalisation. In most hospitals, the staff will help you contact the insurance company for approvals.

Cashless settlement also requires you to take a pre-authorisation from the TPA or the insurance company. This involves filling up a form and sending the details of the procedure, cost of hospitalisation to the insurance company. The hospital will help you in this process.

Now, the insurance company would give its approval of the claim and also specify a ceiling on the total costs. It may also reject the cashless settlement procedure. Do not worry if this happens, as it does not mean the rejection of the claim itself. It just implies that you may have to pay the bills and claim reimbursement later from the insurance company.

CHOOSING THE HOSPITAL

Cashless settlement is done only when you get treated in a hospital that is part of the insurance company’s network. You must go through your medical policy and have a list of hospitals that are near your residence and part of the insurance provider’s empanelled list. It would also be advisable if you have another shortlist of hospitals near your workplace or places in the city that you frequent so that in case of any emergency you can be taken to a network hospital.

Keep your medical policy in a place where you or your family members can easily access it.

In case you are unable to get admitted to a network hospital and have to go to some other place for treatment, you have to pay the bills upfront and later claim reimbursement.

You must be aware of limits of payment for some diseases and also those that require you to spend less than 24 hours at the hospital such as cataract removal. This is pegged at an absolute sum or as a proportion of sum insured. Finally, you need to set aside some cash periodically for emergencies including medical ones. This would help you be prepared for a worst case scenario in case a cashless settlement is not approved.