Let’s say Ajay suddenly has discomfort in his chest in the middle of the night and has to be rushed to the hospital, which is in the insurer’s cashless network. On reaching the hospital, doctors detect a heart attack and recommend immediate hospitalization. Now, the family shows the cashless card to the admission desk, but the admission desk asks for an advance because the TPA/Insurance desk of the hospital is shut in the night! 

This is very common in emergency hospitalizations, especially if they happen to be in the wee hours. 

The family is confused and annoyed. Even you are reading this and thinking: what is the point of having a cashless cover if it doesn’t work during emergencies?

To understand this better, let’s learn the basics. 

What is a Cashless claim?

Long long ago, when cashless facility wasn’t introduced, you needed to pay for the hospitalization expenses out of your pocket first, and then claim for those expenses from the insurance company. This process is called a reimbursement claim. This required families to have some amount of cash ready at all times - to pay off the hospital and get the treatment, and then apply to the insurance company for reimbursement

With the introduction of cashless facilities, insurers have a list of hospitals where you can simply get an early approval from the insurance company - that they will approve your claim and agree to pay the amount directly to the hospital. This was introduced to reduce the burden on your family to arrange a large amount of cash, plus manage paperwork. In the case of cashless, the insurer and the hospital interact and exchange documents, post which the insurer will directly pay the approved amount to the hospital. 

This is comparatively easy - and hassle-free - especially if you’re going through a planned hospitalization. You inform the insurance company in advance, share the doctor’s advice, details of the treatment recommended, approximate costs, etc. They go through your treatment requirements and approve a cost. They promise to pay the hospital directly. 

Usually, when you plan a hospitalization, i.e., you know that you’ll need to get admitted for treatment, surgery, or procedure, you begin your cashless claim by applying for a pre-authorization.

1. Through the hospital insurance desk, you’ll inform the insurance company about the upcoming admission, the treatments involved, and an estimated cost that can be incurred.
2. The hospital insurance desk will request some documents from you as well - including the policy documents, health card, and your identity proofs - and will then submit those directly to the insurer.
3. The insurer will evaluate everything, and approve a pre-authorization for the amount that is eligible to be paid.
4. Post this, you’ll take admission, and go through the needed treatments or surgeries.
5. Before discharge, the final bill is sent to the insurer (again, through the hospital insurance desk itself) which is evaluated, approved, and paid to the hospital, directly by the insurer.
6. If the insurer doesn’t approve certain expenses - this is reflected in the bill as well and, you’ll have to pay for them out of your pocket.

This may not work in emergencies!

In case of emergency hospitalization, you’ll see that you cannot get a pre-authorization in advance. And, that’s what makes it complex.

Insurers could take around 6-24 hours to give pre-authorization as they’ll have to evaluate and verify if you have enough cover, the treatment is covered, etc. And if you’re admitted for an emergency, you won’t really have this time! Hence, the hospital will ask you to make an advance payment before they give you access to their services - despite the cashless facility being available. 

If the admission was due to an accident, which constitutes several emergency situations - you’ll be provided emergency care to stabilize you - but to admit you to a room or a ward - someone will need to pay an advance amount. 

The hospital Desk isn’t open 24x7

To add to the complication, unlike an insurance company that processes claims 24x7, the hospital department that processes the claim on your behalf doesn’t work 24x7. They might have certain working hours and remain close on holidays. So, if you get admitted at a time when the hospital desk is not open, the cashless claim process won't even be initiated until the next working hour. So, you’ll need to put out an advance.

Will the hospital return the advance payment?

The advance payment that you make to the hospital is later refunded by the hospital when the insurance company approves the cashless claim request - which could be 6-12 hours after the submission of all the documents and bills. Hospitals may, however, keep a small portion of the deposit for deductions that the insurer may make in the final approval - that is after your discharge papers, and the final bill is cleared. 

This can be disappointing, we know. But don't fret. 

What can you do to ensure the best cashless claim settlement experience?

Here are three things you can do to ensure that you have the best cashless claim settlement experience - 

1. If your treatment is a planned one, visit the hospital beforehand and begin the process for your cashless claim. This will ensure that the cashless is approved on the date of admission and you do not have to pay any advance.
2. Always maintain an emergency fund + an active credit card. They will come in handy in case you need to pay an advance for getting admitted or treated at the hospital.
3. Keep soft copies of your cashless card, policy document, and Aadhar card of your family members in an easy-to-access drive folder on multiple smartphones in your house. This will ensure you have access to all the documents you need for an admission ready - even in an emergency. 

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