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Health Insurance Benefits

Tax Benefits
u/s 80 (D)

Cashless
Treatment

Free Annual
Health Check up

Cashless Claim Does Not Serve Emergency Hospitalisation

Back in the day, you had to pay for the hospitalisation costs first out of your own pocket, then claim them from your insurance. This is called a reimbursement claim. It meant that you had to arrange for cash to pay off the hospital bill, get medical treatment, and then claim a reimbursement from the insurance company.But, the scenario has changed now. Insurance companies have a list of network hospitals for which you can get early approval that the insurance company will authorise your claim and pay the hospital directly. This is known as a cashless claim.The cashless claim feature is definitely a blessing in disguise when your hospital stay is well-planned in advance.But what if a medical emergency occurs? Accidents or sudden medical crises don't tell and happen. And, hospital bills are the last thing you want to worry about when you or your loved one is rushed to the hospital.The general perspective is that if your insurance company offers you a cashless claim feature, you will never have to pay a single rupee yourself. This is not entirely true.Let's have a detailed look.

How Does A Cashless Claim Help?

A cashless claim is quick and simple. You need to get treated in a list of hospitals affiliated with your insurance company, who shall pay the approved medical bill amount directly to the hospital if you get an early approval from the insurer. You just have to pay the non payable expenses and you are done.With cashless, you may no longer have to arrange huge sums of cash and worry about paperwork. The insurer and hospital communicate and exchange documents between themselves.

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How Do You File A Cashless Claim?

Here’s a quick checklist of how the cashless claims process works -

Contact the hospital’s insurance desk and inform your insurance company about the hospitalisation, recommended treatment, estimated cost of treatment, etc.

You will also need to provide some documents to the hospital insurance desk, so they can submit them directly to the insurer. Required Documents include your health card, identity proofs, policy documents, etc.

The insurer will evaluate all the provided documents and provide a pre-authorization for the eligible amount that can be paid. A pre-authorisation is essentially an initial promise that the insurance company will pay your hospital bills.

Following this, you can undergo the necessary treatment or surgery.

Before discharge, the hospital insurance desk will send your final bill to the insurance company. They will then evaluate the same and provide a final authorization, after which the payment will be made directly to the hospital.

You will not be required to foot any approved expenses, they will be paid directly to the hospital by the insurance company. Any expenses not approved will be reflected on your bill and you will be liable for them.

This cashless claims process is extremely convenient, since you don’t have to run from pillar to post to get your reimbursement approved from the insurance company. Everything is handled by the hospital and insurance company.However, cashless claims may not work when it comes to emergency hospitalisations.

Cashless Claims May Not Help In Emergencies!

A cashless claim is not an emergency service. While it can be used for emergency hospitalisations too, it may not actually work on ground, due to shortage of time.

Here’s why -

1 Pre-authorisation may take time

Pre-authorisation takes around 6 to 24 hours, since the insurance company manually evaluates your policy coverage, whether your treatment aligns with policy conditions, etc.Now, you can’t wait that long during emergencies and the hospital will not process the admission without a pre-authorisation. Hence, despite the availability of a cashless facility, the hospital will require advance payment before you get access to their medical facilities.
The TPA desk at the hospital doesn’t remain open 24x7

The TPA desk’s working hours may vary and it may be closed on holidays. You won't even be able to initiate a cashless claim until the next working hour if you are admitted during off-hours at the hospital. Advance payment may be required in this case, so you need to plan accordingly.

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Tips To Ensure A Smooth Cashless Claim Settlement Experience

For planned treatments, you should visit the hospital beforehand to initiate the cashless claim process. So, the cashless will be approved on the day of admission and that no advance payment will be required.

A credit card and emergency fund should always be kept on hand. This will be handy if you need to pay an advance to get admitted to the hospital or receive treatment.

You should save soft copies of your cashless card, policy document, and Aadhar card on your devices so that you or your family can access them easily, even if there’s an emergency.

Summing Up!

So, this was all about how cashless claims function during emergencies. Make sure you keep in mind the limitations it has and how you can avoid any unpleasant situations.

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We were fortunate enough to have selected SMC as our Health Insurance Broker for they have been very helpful in resolving our queries related to health insurance. I would like to cite two examples where SMC's role has been very crucial. One was when payment for cashless hospitalization was not coming through as the insurance company was taking undue longer time to approve the Hospital Bill. It was then I talked to Neha and it was she who through her contacts in the Insurance co. facilitated and expedited the approval for payment of hospital bill. Second was very recently when the Insurance co. had proposed a top up "Enhancer" policy for our existing policy. When I talked to Neha she immediately told me not to take this policy being offered without any medical test as it will not be beneficial to us and may create problem later on account of recent hospitalization. If I had I not consulted Neha, I would have into a big trouble with the insurance co. These two instances speak very high of sincere advice and timely help rendered by the SMC Staff, Ms. Neha Khanna which helped us a lot in time of need.Show More

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My experience with SMC Brokers is excellent. They provide support from the beginning till end i.e from issuance of insurance policies till settlement of claims. They explain very nicely various provisions relating to Insurance Policy also facilitate settlement of claims with Insurance Companies. Show More

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