Cashless versus reimbursement: How to make the right choice when filing a health claim

Cashless and reimbursement claims have their own unique advantages and disadvantages. Find out which one works best for you.

Cashless versus reimbursement How to make the right choice when filing a health claim

A health emergency requiring hospitalisation can have both short term and long term implication for your financial goals. Health insurance is fast becoming a priority for many Indians due to the rising costs of quality healthcare. Health insurance companies too have been focusing on providing a host of customer-friendly features such as cashless or reimbursement mode.

What is difference between cashless versus reimbursement hospitalisation?

Simply put, with a cashless health insurance cover, the policyholder need not pay for any medical bills out of pocket. The same is settled directly between the insurance company and the hospital.

With a reimbursement health policy, the insured has to bear the medical costs initially. Which are subsequently reimbursed by the insurance provider on submission of bills.

So, which one is better, cashless claim or reimbursement hospital claim? Let’s compare both and analyse which is the better of the two:

How does cashless insurance work?

Cashless health insurance plans allow the insured to avail medical care without having to pay upfront. The insurance company settles the dues directly with the hospital, provided it is a part of its network. The bill is paid subject to all policy terms and conditions being met.

For emergency hospitalisation:

  • In the event of an emergency, the hospital will begin treatment as soon as you furnish the cashless card  and insurance policy details at the admissions desk.
  • The hospital will then contact the insurance company for approving the treatment. It will submit a pre-authorisation form on your behalf, in order to get the go-ahead.
  • The bills are reviewed on completion of treatment by the insurance company which makes the payment accordingly.

Related: Eight health insurance myths debunked

For planned hospitalisation:

  • Here, you need to get approval from the insurance company beforehand by submitting the required medical reports and cost estimates.
  • If approved, the insurance company issues a pre-authorisation letter which is to be submitted at the hospital on admission along with the health insurance policy details, including the health insurance ID card.
  • At the time of discharge, however, the hospital will retain the bills in order to claim payment from the insurance company.

Reimbursement health insurance claims process:

  • If you do not have a network hospital nearby, you can approach a non-network hospital of your choice and claim reimbursement later. In the meantime, you will need to pay for the treatment costs yourself, including room charges and medicines.
  • Once you file a claim, the insurance company will review the treatment-related information such as the discharge report, treatment details and of course, original bills.
  • It will approve the claim if the documents satisfy all the criteria outlined in the insurance policy.
  • If the claim is declined, the insurance company provides the exact reason for the same.

Related: Things to note when purchasing health insurance during COVID-19 pandemic

Which one should you choose?

Both reimbursement and cashless claim facility in healthcare have their advantages. With cashless claims, you can focus all your attention on getting the best possible treatment. However, you can only avail this benefit at a network hospital which may or may not be in your vicinity.

In the case of reimbursement claims, you have the freedom to choose a hospital of your choice, however, the expenses will need to be borne by you and claimed later.

To avoid any hassles:

  • Get pre-authorisation approval as for planned treatment as early as possible to avoid claim delays.
  • Ensure that all documents and receipts are in order at the time of filing a reimbursement claim as the insurance company is likely to ask for too many clarifications regarding document requirements or other justifications, resulting in delays. Are unprecedented pandemics covered under health insurance? Check this piece to get answers to all your queries?


Related Article

Premium Articles