What is a Cashless Claim?

With a cashless claim, the insured is not required to pay for all the treatments and procedures covered under the policy except for the non-medical items. The claim is settled by the insurer who pays to the hospital directly according to the terms and conditions of the policy. Cashless benefits can be availed for both planned and emergency medical treatments.

The Steps Involved in Cashless Claim

  • 01

    Pre-authorisation

    The pre-authorisation process is required to establish trust between the insurance company and the insured. The pre-authorisation process is done to check the eligibility of the claim and to initiate the cashless claim process. This is done when the insured presents the health insurance policy card and a government approved identity card to the hospital.

  • 02

    Enhancement During Admission

    When the estimated expense for a medical treatment that is sent at the time of pre-authorisation is lower than the actual amount, then the hospital sends the new expected figure to the insurance company and this is known as an enhancement during admission.

  • 03

    Queries in Cashless Admission

    If any queries are raised during the investigation process of the medical treatment, the hospital needs to resolve those queries.

  • 04

    Cashless Discharge

    Once all the data points are accurately established, the insurance company will settle the payment directly with the hospital.

What is a Reimbursement Claim?

If the hospital where the patient is treated is not a part of the insurance company’s hospital network then the insured has to opt for a reimbursement claim. This requires the insured to pay the hospital bill in cash at the time of discharge and get the payment reimbursed by the insurance company at a later stage. In comparison to cashless medical claims, reimbursement claims are relatively tedious and time-consuming.

The Steps Involved in a Reimbursement Claim

  • 01

    Claim Intimation

    In the case of a reimbursement claim, the insured needs to intimate the insurance company about the admission of the patient to the hospital.

  • 02

    Collecting Documents in the Right Order

    Pre-authorisation is not required in the case of reimbursement claims, but the policyholder is required to collect all the documents and submit them in the right order.

  • 03

    Getting the Documents Reviewed by an Expert Agency like SureClaim

    It is very important to ensure that all the documents are complete and verified by a SureClaim expert before the claim is submitted for reimbursement.

  • 04

    Filling the Claim Form

    The insured can fill the claim form online or by hand or under the guidance of a SureClaim Expert to avoid mistakes and claim rejection.

  • 05

    Claim Submission

    The claim should be submitted with all the required documents listed in the policy terms.

  • 06

    Claim Tracking and Query

    Generally, the insured can keep a track of the claim status online from the insurance company’s website or get in touch with the TPA on their toll-free number. Meanwhile, if a query is raised by the insurance company, the policyholder needs to address it on time.

  • 07

    Query Resolution Advice by an Expert Agency like SureClaim

    The insured should counsel a SureClaim expert for clarity and guidance on resolving the query raised by the insurance company.

  • 08

    Claim Approval and Settlement

    Once all the queries that are raised by the insurance company are resolved in a timely manner and all the documents are verified, the insurance company will approve the claim and settle the payments.