Types of Health Insurance Claims & Diff between Cashless vs Reimbursement Explained
What is a Health Insurance Claim?
A health insurance claim is the process by which a policyholder (you) requests financial benefits and other related services covered by their policy from their insurance provider (us).
Let’s understand it in simple words!
When you need money to pay for treatment for any major or minor illnesses or any other medical condition covered by your health insurance plan, you can file a claim.
You have to provide all information about the medical costs and the necessary paperwork to approve the claim. Once the claim is made, the insurance company reviews and authorizes it.
What are the Types of Claims in Health Insurance?
A health insurance plan's only objective is to provide financial support to you in times of emergency. To receive this financial assistance, you must file a claim.
There are two types of medical claims that a policyholder can file:
Let’s understand both types of claims in detail.
What is a Cashless Claim in Health Insurance?
A cashless claim is a type of health insurance claim where you can get treated at a network hospital without paying out of your own pocket. Instead, the costs are sent directly from the hospital and settled by the insurer.
So, to get a cashless claim, you can head to one of your insurer’s network hospitals and show them your health e-card and ID proof.
Remember that you need to get your claim approved by your health insurer:
- This should be done at least 72 hours in advance if you’re going for planned hospitalization.
- Within 24 hours of being admitted in case of a medical emergency.
Then, you can get all your treatments done and share the required claims forms with the Third-Party Administrator (a mediator between the hospital and your health insurer). And that’s it. The insurer will take care of your claims.
What is a Reimbursement Claim in Health Insurance?
The second type of health insurance claim are reimbursement claims. In this type of claim, you can visit any hospital, not just those under your insurer’s cashless network. Here, you get your treatment done at the hospital, pay out of your pocket, and then apply for reimbursement for the expenses with your insurer.
When making the claim, you must submit all your hospital bills, prescriptions, medical documents, and other important documents. These will need to be approved before your claim is processed, meaning it can take slightly longer to get through.
Difference Between Cashless and Reimbursement Claims in Health Insurance
Here’s a quick table to help you understand the key differences between the two main types of health insurance claims – cashless and reimbursement:
Health Insurance Claim Process
You can submit a claim against your policy online or in writing to your policyholder to recover your hospitalization expenses. For example, if you have taken Digit’s Health Insurance, here are the steps to get a cashless and reimbursement claim.
Cashless Claim Settlement Process
Step 1: Choose any 9000+ Network Hospitals at Digit for a cashless claim.
Step 2: Notify us within 24 hours of being admitted to the hospital in case of an emergency or at least two to three days before any scheduled hospitalization.
Step 3: Present your e-health card to the hospital's help desk or insurance support desk and get the pre-approval paperwork.
Step 4: Complete the form, sign it, and turn it in at the support desk.
Step 5: If everything is verified, you can proceed with the treatment using the cashless facility.
Reimbursement Claim Settlement Process
Step 1: Call us within two days after being admitted to the hospital.
Step 2: You will receive a link to upload soft copies of all original documents (bills, reports, etc.) along with the bank account information of your choice.
Step 3: You must personally sign each document before uploading.
Step 4: Upload the documents after you obtain the link or within 30 days of the discharge date.
Step 5: You will be paid within 30 days after verification and approval of the document.
Different Types of Health Claims at Digit
Health insurance claims are the backbone of any health insurance policy, offering financial support when needed. Digit Health Insurance provides two major claims types: cashless and reimbursement.
Let's understand the different types of claims offered by Digit:
1. Cashless Claims
Under the cashless claims option, all expenses incurred at a network hospital are directly settled between the hospital and the insurer. This ensures that policyholders do not have to pay out of pocket at the time of hospitalization, except for exclusions or deductibles outlined in the policy.
However, if a cashless claim is not processed for any reason, policyholders can switch to a reimbursement claim.
2. Reimbursement Claims
Reimbursement claims come into play when treatment is availed at a non-network hospital or if a cashless claim cannot be processed. Digit offers the following types of reimbursement claims:
- Outpatient Department (OPD) Claims: OPD claims cover expenses related to medical consultations, diagnostic tests, and minor procedures that do not require hospitalization. Policyholders can claim these expenses by providing valid receipts and prescriptions.
- Pre and Post-Hospitalization Claims: These claims cover medical expenses incurred before and after hospitalization. Pre-hospitalization claims include costs like diagnostic tests and consultations leading up to the hospitalization. Post-hospitalization claims cover follow-up consultations and medicines required after discharge.
- Advance Cash Claims: Policyholders can opt for an advance cash facility in certain cases and limitations. This allows them to receive a lump sum amount in advance to cover anticipated medical expenses, offering financial relief during emergencies.
- Annual Health Check-Up (AHC): Digit also offers an Annual Health Check-Up (AHC) benefit. This feature enables policyholders to claim a portion of their expenses for routine health check-ups. However, this benefit comes with a limitation and can only be availed depending on your health insurance policy terms.
FAQs about Types of Health Insurance Claims
What are the benefits of a cashless health insurance policy?
There are several benefits when it comes to having cashless insurance. It includes:
- Fast Claims: Cashless claims are usually processed much faster.
- No Cash Needed: You don’t have to dip into your savings for medical expenses and then wait for reimbursement.
- No Paperwork: A cashless policy involves almost no formalities and paperwork.
- No Hassles: In a cashless claim, payments occur between the hospital and the insurance company so that everything will be handled.
What is a network hospital?
A network hospital is a hospital that has a tie-up with your insurer. Once it is part of your health insurer’s network, you will be able to get the option of cashless treatments at that hospital.
Do I also have to pay anything from my pocket during a cashless claim?
This will depend on whether or not your health insurance has a co-payment clause. In this case, even with a cashless claim, you must pay the co-payment amount out of pocket.
For example, if the co-payment is 10%, you must pay 10% at discharge and the rest 90% will be cashless. But if your insurance doesn’t have a co-payment clause, you don’t need to pay anything from your pocket during cashless claims, as long as your hospital bill is less than your total sum insured available.
What documents must you submit while making a cashless or reimbursement claim?
The documents you need will depend on the kind of claim you make. For cashless claims, you just need to fill out the required form given by the TPA at the hospital. On the other hand, for a reimbursement claim, you will need to submit your health invoices, including medical bills, doctor’s prescriptions, etc.
What is the meaning of a health insurance claim settlement ratio?
The total number of health insurance claims an insurance company settles during a fiscal year relative to the total number of claims received is the claim settlement ratio. The health insurance claim settlement ratio increases the likelihood of resolving your claims.
How much can be claimed from health insurance?
The sum insured limit is the maximum amount you can claim under your health insurance policy. You can claim the sum insured amount in one or multiple claims annually.
Can I make a health insurance claim without being admitted to the hospital?
Yes, you can claim your health insurance without staying in the hospital under OPD and domiciliary hospitalisation coverages.
What is a Health Card?
A health card is an identity card for the insurance company's health insurance policy. It facilitates claim registration and settlement history tracking.
Does a cashless claim also require me to make any out-of-pocket payments?
Yes. When your health insurance has a co-payment clause, it will determine whether you must pay any out-of-pocket expenses. In such a case, even if you file a cashless claim in this situation, you will still be responsible for paying the co-payment out of pocket.
However, you won't have to pay anything out of pocket if your insurance has no co-payment provision.
Does my health insurance coverage have a waiting time before I can file a claim?
Yes, your insurance coverage does have a waiting period. The initial waiting period before claiming any health insurance is usually 30 days, but this waiting period in health insurance differs from insurer to insurer.
Therefore, consult your insurance provider or read your policy document to prevent unpleasant surprises when it comes to settling your claim.
When is the time to make a health insurance claim?
Claims for health insurance can be filed as follows:
- 72 hours before the scheduled hospital stay for cashless claims
- Within 24 hours of emergency hospitalization for cashless claim
- A reimbursement claim is filed within the time frame the insurer specifies when you submit your document after hospitalisation.
Under what circumstances can my claim be denied?
The following situations may result in the denial of health insurance claims:
- No pre-existing medical conditions are declared at the beginning of the coverage.
- Failure to notify the insurer within the allotted period and delay the claim submission.
- When any supporting documentation is not included with reimbursement claims.
- When the policyholder chooses a cashless claim benefit and receives treatment in a hospital outside the insurance provider's network of facilities.
I recently bought myself and my family a health insurance policy. Can I claim without using cash?
Yes, you can claim a health insurance policy for you and your family without using cash or using a cashless claim in a network hospital.
How can I determine if I should file a reimbursement or cashless health insurance claim?
A simple and hassle-free way to resolve disputes is through cashless claim settlement. One can use the cashless claim if the therapy is offered in a network facility and the hospitalization is scheduled. However, one might file a reimbursement claim in an emergency when they cannot check the network hospital list or if the treatment is not offered.