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Cashless or reimbursement mode in claims


Cashless or reimbursement. Customers should always opt for cashless treatment if they have the choice. Here's why

  • Insurers formulate hospital packages for particular LoT based on a lot of research. They subsequently onboard hospitals to discharge services at these rates (packages). All of this is done to ensure standardization of rates, so that hospitals charge based on LoT and not the purchasing power of the Customer.
  • Prudent money management dictates money in hand is better than money outgo at a later point in time.

While cashless facility should always be the Customers first choice, there could be times when she might be unable to avail the facility because

  • The hospital is not empanelled with the Third Party Administrator (TPA).
  • The TPA is doubtful about the admissibility of the claim under the terms and conditions of the policy.

Incase of a planned hospitalization, always check with the TPA for a hospital which will provide a cashless facility under the policy.

A complexity to note here is that cashless facilities are policy specific, i.e. a TPA might provide cashless facilities at a hospital for one policy by an insurer and yet deny cashless under your policy. This happens when hospitals accept package rates for LoT under a particular policy but not under another - for eg. Mrs. Mehta has two mediclaim policies, a Group Mediclaim Policy (GMP) by her employer ABC Ltd and she is also covered as a dependent under her husbands GMP by XYZ LTD. It could happen that an Apollo facility in Delhi offers cashless under the ABC Ltd policy but not under the XYZ Ltd one. The terms of empanelment could vary for the same insurer across different policies.

If for some reason you do have to opt for reimbursement, ensure to

  • Check with the TPA for all the documents you need signed/ stamped from the Hospital. Getting this done while you are still at the Hospital saves you time, a trip to the Hospital and unnecessary arguments with the Hospital staff.
  • Keep a copy of all the documents submitted to the TPA, in case they misplace the set you submitted.
  • Get an acknowledgement of all the documents submitted to the TPA.

In case you need to split your hospitalization expense across two policies, you will need to get a certificate of settlement (which will specify the amount settled by the first TPA) and coordinate the document exchange between the two TPAs.