The Economic Times
10, March 2010

Cashless mediclaim is not a new concept anymore. As the name suggests, you can get hospitalised, undergo surgery or both without having to pay cash at the time of bill settlement. The insurance company settles the bill directly through its third-party administrator (TPA) whose contacts are usually provided along with the policy. The hospital would require the patients ID card to check the policy details so as to deliver the cashless service. But this easy insurance works only under certain conditions.

Can you avail of cashless mediclaim in all hospitals?
Every insurer has a list of hospitals in which you can use the cashless facility. You can get this information in the insurance company’s website and cross check with the TPA. The list, however, is subject to change as hospitals frequently have disagreements with insurers and drop the cashless arrangement. If the hospital of your choice is not on the list, you can still avail of treatment there. However, you will have to pay for the treatment at the first instance and later get a reimbursement from the insurer by submitting your bills. The average time taken for reimbursing bills is 20 days.

Whom should you approach if there is a problem with your cashless mediclaim?
Although the insurance policy would have been issued by some general insurance company, third party administrators play an active role in cashless mediclaim. The payment usually is made by the TPAs. Most of these TPAs provide administrative support to the insurance companies for servicing their insurance policies. As far as you are concerned, TPAs are the main contact point for settling claims. If the insurance company fails to stick to its contract, you can complain to the insurance ombudsman whose contacts are available on the Irda website.

What happens if your cashless mediclaim gets partly reimbursed?
This doesn’t mean that the claim has been rejected by the insurance company. The claim has been rejected at the TPA’s end. TPAs sanction the claim amount based on a clause called “customary and reasonable charges”. They keep a database on average costs of various surgeries across cities. Based on this database, the TPA sanctions the claim amount.

Usually, a surveyor visits the hospital to validate the claim. At times, the TPA approves a part of the amount and the balance has to be borne by you. In extreme cases, the TPAs reject the claim if the surveyor is suspicious of the patient or hospital’s credibility. In such cases, you have to settle the hospital bill and take up the case with the TPAs/insurer later.

How can you avoid part-payment or rejection of the claim?
In case of planned surgeries, you should check the approximate bill amount with the hospital. Then, you could check with the TPA on the size of the claim amount and its likely settlement. Often, even hospitals should take an in-principle approval from the TPA to avoid last-minute hassle in the case of planned surgeries. In fact, some TPAs make it mandatory for patients/hospitals to take prior in-principle approval except in case of accident-related claims.

Can you use cashless facility abroad?
Yes, you can, provided you have an overseas students mediclaim or a travel policy. Private insurers have tie-ups with hospitals abroad. Still, it is advisable for travellers or students to take a prior in-principle approval as mentioned above.