Back to the Basics – Breaking Down Reimbursement & Cashless Health Insurance Claims

Have you ever wondered what the world was like when health insurance didn’t exist? Imagine having to pay enormous sums for simple medical treatments. For the average person, a single medical diagnosis can wipe out their entire savings and drown them in mountains of debt. But with health insurance, you can get high-value coverage. Plus, you can seek treatment at your preferred hospitals. In some situations, you don’t even have to pay anything upon getting admitted at the hospital. Technically, these facilities are called reimbursement and cashless claim procedures respectively and here’s all you need to know about them.  

Health Insurance Claims – What’s the Gist? 

When you fall ill, you need treatment. If the illness is severe, you may need hospitalization, leading to high expenses ranging from pre-surgery costs to physicians’ and hospital staff’s charges, medications used during and after the surgery, hospital room rent charges, and so on. These costs keep multiplying.  

Now, if you have health insurance, you can raise a claim to cover these costs. This simply means that your insurer pays for these costs, up to a limit known as the ‘sum insured’, i.e., the maximum coverage amount. The health insurance claim process is typically categorized into two types: 

1. Reimbursement Claims 

Say you need treatment for dengue fever. Your family doctor asks you to seek admission in XYZ hospital immediately. You then find out that the hospital your doctor recommended is not part of your insurer’s network. Now, if you have health insurance, all you have to do is bear the treatment costs upfront, collect all the bills, and fill out a claim form. Your insurer reviews your claim and reimburses you for the expenses incurred, up to the sum insured. 

In simple words, a reimbursemesnt claim allows you to seek treatment at your preferred hospital. Once you are discharged, you can file a claim and get a refund for the expenses incurred.   

2. Cashless Claims 

Insurers understand that your medical bills can increase your financial burden. So, they offer a facility known as cashless claims. Under this health insurance claim process, you need seek hospitalization at one of the thousands of hospitals within your insurer’s network. Your preferred hospital may also be on this list. By opting for the cashless mediclaim process, you can do away with the stress of paying for the treatment costs upfront. 

With cashless claims, your insurer’s representative directly deals with the hospital and takes care of billing. You just need to inform the insurer about the network hospital you’ve chosen for treatment. 

Health Insurance Claims Procedures – The Steps You Need To Follow 

Now that we’ve covered the basics of reimbursement and cashless claims procedures, let’s dive into the steps to follow based on your chosen mediclaim process. 

For Reimbursement Claims 

The steps for the medical claim reimbursement process can be summarized as below: 

1. Inform the insurer 72 hours before or within 24 hours of hospitalization (during urgent hospitalizations) that you intend to raise a claim. 

2. Seek the treatment per your physician’s recommendations, pay the medical bills, and get discharged from the hospital.  

3. Begin the claim filing process by obtaining/downloading the claim form from your insurer’s website and fill out all the requested details. 

4. Gather all the treatment-specific documents – diagnosis reports, original hospital bills, discharge card, etc., and submit them with the duly-filled claim form. 

5. Your insurer will verify your claim, ask for more documentation if required, and reimburse you for your medical expenses, typically within 21-45 days.   

For Cashless Claims 

Let’s now look at the steps to follow in case of a cashless health insurance claim process: 

1. Check the insurer’s list of network hospitals, and choose one for hospitalization. Remember to inform your insurer and get pre-approval. 

2. Present your health card/ policy at the hospital’s insurance desk, obtain and fill out a pre-authorization form and get admitted. 

3. The insurer will send an approval letter to the hospital and their representative or a third-party administrator (TPA) will manage the hospital bills. 

4. Contact the insurer again at the time of discharge. Their representative will complete the billing formalities and pay the bills up to the sum insured amount. 

5. Get discharged from the hospital, collect the pre and post-hospitalization bills and file a reimbursement claim.  

Things to Remember 

• You can follow reimbursement and cashless claim procedures for planned as well as urgent hospitalizations. 

• In case of a planned hospitalization, you should inform the insurer at least 48-72 hours before seeking admission in the hospital. 

• For urgent hospitalizations, you must inform the insurer within 24-48 hours of hospitalization – the earlier the better. 

• Hospitals may ask you to put down a security deposit during last-minute hospitalizations, even if you choose a network hospital. This amount will be refunded or adjusted upon discharge. 

• Irrespective of your chosen health insurance claim process, you must file a reimbursement claim for pre and post-hospitalization expenses. 

Reimbursement and Cashless Claim Procedures – Which is Better? 

Whether you should choose cashless claims or health insurance reimbursement processes depends on various factors.  

• The situation at hand 

During medical emergencies, you would want to choose a hospital in your vicinity. If a network hospital is available, you can choose it and enjoy cashless claim benefits. If not, and you can’t afford to waste time, it’s best to head to your nearest hospital, get treatment, and file a reimbursement claim later. 

• Your Affordability  

If the hospital near you, levies high treatment costs, which may exceed your policy’s sum insured amount, you may consider another hospital that charges lower costs. This applies to both reimbursement and cashless claim procedures as, in both cases, you need to bear the excess costs from your pockets. 

• Your Preference 

Your preferences typically come into play during planned hospitalizations where you generally have a few days to choose a hospital for treatment. if you wish to seek treatment at a specific hospital, you can choose the mediclaim reimbursement process if your preferred hospital isn’t in the insurer’s network. If it is, you can opt for the cashless mediclaim process. 

Manipal Cigna Health Insurance – Simplifing Health Insurance Claim Processes Since Inception 

At Manipal Cigna Health Insurance, we follow a customer-first approach. This is evident in all the necessary measures we take to ensure you enjoy an easy and streamlined claim-filing process. You can raise both cashless and reimbursement claims and even submit your documents online. What’s more, we offer a myriad of health insurance policies to suit your diverse coverage requirements and budget. 

Invest in health plans that makes a difference – Buy A Manipal Cigna Health Insurance Policy Today.  

Reimbursement and Cashless Claim Procedures – The Most Frequently Asked Questions 

What is a health insurance claim?  

A health insurance claim is a process your must follow when you encash your health policy. Under this process, you typically need to inform your insurer about your wish to file a claim, get the necessary treatment, and submit the duly-filled claim form along with the required documents.  

What are the different health insurance claim processes? 

Health insurance claim processes are broadly classified into two types – reimbursement claims and cashless claims. In the former, you must bear the medical costs upfront and file for reimbursement later. In the latter, you can seek hospitalization at a network hospital on a cashless basis.  

How much time do insurers take to settle reimbursement and cashless claims? 

Insurers usually take 21-45 days to settle reimbursement claims. They settle cashless claims in tranches, with a turnaround time of 2 hours after each transaction is raised. 

I have opted for cashless claims. What happens if my medical expenses exceed the sum insured? 

If your medical expenses exceed the sum insured amount following a cashless claim, you have to bear the costs yourself and clear the bills before being discharged from the hospital. 

What documents must I provide if I opt for cashless claims? 

If you opt for a cashless claim, you need to present the health card provided by your insurer at the time of buying the policy. You can also provide a copy of your health insurance policy.