When can your cashless claim get rejected and what next?

When you buy health insurance, most companies promise a cashless claim at the hospital. With a cashless claim, the insured can be admitted to a Network hospital without any deposit at check-in and has to bear no medical bills after the commencement of the treatment.

The magical insurance card, submitted at the time of the treatment does the trick. The hospital contacts the insurer and the company settles the bills directly. The insured just needs to take care of the overhead expenses, like extra services if any is availed.

But sometimes this cashless claim is declined. Let us examine the scenarios and see the solution to them.

When you check in a Non-Network Hospital

Every insurance company has a list of network hospitals in particular pin codes. This means that insurer has a tie-up with these hospitals and you can avail a cashless treatment there.

However if in case of an emergency or any other situation, if one decides to get admitted to another non-network hospital, the bills have to be cleared initially by the insurer and then one can go for a reimbursement claim (Explained below)

If the hospitalization is due to a pre-existing conditions in the initial years of the policy

A pre-existing condition like diabetes may not be covered in the insurance policy for 3-4 years. So if a person with advanced diabetes is admitted to the hospital because of stroke, then one may not receive the cashless claim, as it is a condition arising from diabetes. In such a situation, it is important to read the policy details carefully and know the time after which pre-existing conditions are covered.

Non-Disclosure or Incorrect mention of facts during policy purchase or claims

A cashless claim can be rejected, in the event of a discrepancy in details entered while buying or claiming the policy. This can be non-disclosures, partial disclosures and wrong disclosures of significant facts such as age, nature of the occupation, income, existing insurance policies, major ailments or pre-existing medical conditions. Coverage is offered based on the information provided by the insured on the proposal form and hence any gap between what is declared and the reality at the time of filing claims can be a reason for rejection. So, always answer all questions honestly when you apply for a health policy.

Superfluous Expenditure on a treatment or service from the hospital

Sometimes, a hospital, in its quest to generate maximum revenue, may perform medical procedures which may not be necessary, on patients covered by a medical insurance policy. The policyholder is also relaxed about it as he mistakenly assumes the money will be paid by the insurance company.

What to do when your Cashless Claim Gets Rejected

If a cashless claim is rejected, for any reasons, then one can still be eligible for a reimbursement claim. In such a situation,

  1. Immediately notify the insurance company or the Third Party Aggregator (TPA) about the hospitalization and rejection of the claim.
  2. Clear your hospital bills upon discharge.
  3. Fill and sign the Reimbursement claim form of the insurer. You can find it on their website, under the claims tab.
  4. Submit the claim form along with all the hospital documents, at a branch of the insurance company or TPA near you.
  5. Track the progress of your claim and stay in touch with the insurance company.  

In order to avoid any of the above situations, be sure to understand your policy document clearly. It is also advised to compare all the plans out there. Visit Turtlemint to find a policy, which suits your needs.

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