Cashless Health Insurance Claims and Reimbursement Explained

Cashless Health Insurance Claims and Reimbursement Explained

There is a lot of misinformation and confusion when it comes to understanding different insurance terms and commonly used definitions. For instance, many people think that treatment in a network hospital is mandatory for a health insurance claim. However, when you do not choose a network hospital for a treatment, your claim is not automatically rejected. The difference is that in a network hospital, which is affiliated with your insurance provider, you do not have to pay anything upfront, as the treatment is on a ‘cashless’ basis.

On the other hand, in the case of a non-network hospital, you end up paying the amount upfront, then raising the bill with your insurance provider, and your bills are reimbursed accordingly. Here, you first need to pay everything out of your pocket; the waiting periods are long, and the entire paperwork is between you and the hospital, with your insurer only coming into the picture post-discharge of the patient.

Want to know more about the two concepts? Let us understand how cashless health insurance and reimbursement claims work, and which one you should choose in different circumstances.

What Are Health Insurance Claims?

A health insurance claim refers to a formal request made by the patient or any person insured by the plan to the insurance company to cover the medical expenses incurred. When the hospitalisation occurs, filing a claim through a TPA (Third Party Administrator) or directly to the insurance company is critical to access the benefits promised under the policy.

Whether the claim is cashless or reimbursed depends on the type of plan you have chosen and whether the treatment is performed in a network or non-network hospital. Both processes aim to ensure that the individual receives the best medical treatment and that financial stress can be reduced.

Types of Health Insurance Claims

Reimbursement Claims

When a policyholder opts for a hospital not part of the insurer’s network, they may have to pay bills upfront and later claim reimbursement.

How reimbursement works step by step

• The insured pays all bills at the time of discharge.
• They collect documents such as discharge summaries, prescriptions, and medical bills.
• These documents are submitted to the insurer or TPA.
• After verification, the insurer reimburses the approved amount directly to the policyholder’s account.

Advantages and limitations of reimbursement claims

Reimbursement claims offer flexibility to choose any hospital, but can cause financial strain since the insured must pay upfront. Settlement also takes longer due to document verification.

Cashless Claims

These are the claims where an individual does not need to pay anything upfront, and all the settlement is carried out with the hospital directly (by the insurance company).

How cashless hospitalisation works

• The policyholder chooses a network hospital.
• The hospital initiates a pre-authorisation request to the insurer.
• After approval, the insured gets admitted and treated.
• On discharge, the bill is settled between the insurer and the hospital.

Benefits of cashless claims

First, your savings are not affected even for a day, as you do not need to arrange money in a health-related emergency. The entire process from treatment to discharge is faster and convenient for the patient.

How Do Health Insurance Claims Work?

General process flow

• Visit a hospital for treatment.
• Submit policy details and ID proof.
• Hospital/insured notifies insurer or TPA.
• The claim is reviewed and settled either on a cashless or reimbursement basis.

ManipalCigna’s streamlined claim process for customers

ManipalCigna has simplified claim management with a wide hospital network , 24/7 support, and digital tracking tools. This ensures approvals are faster, paperwork is reduced, and customers face minimal delays.

Claim Process in Detail

For Reimbursement Claims

Documents required

Key documents include claim form, discharge summary, prescriptions, diagnostic reports, pharmacy bills, and original hospital bills.

Timeline for settlement

Most reimbursement claims are settled within 7–15 working days after verification of all documents.

Common challenges and how to avoid delays

Delays often occur due to missing reports or incomplete forms. Policyholders can avoid these issues by keeping medical records organised and notifying the insurer immediately after discharge.

For Cashless Claims

Network hospital admission process

The insured must select a network hospital, show their policy card, and request admission under cashless coverage.

Pre-authorisation request

Hospitals send estimated treatment costs and details to the insurer for approval. This usually takes only 1 hour for planned admissions and less for emergencies.

Final settlement after discharge

The insurer verifies the final bills against the pre-authorisation and pays the hospital directly. Only non-payable expenses like consumables may need to be paid by the patient.

Cashless vs. Reimbursement Claims: Which Is Better?

• Based on the situation at hand (emergency vs planned): Cashless is ideal for emergencies, while reimbursement is useful for planned treatments at non-network hospitals.
• Based on affordability (upfront payment vs cashless relief): Cashless claims suit those who cannot afford to pay large bills upfront.
• Based on preference (customer convenience vs flexibility):Cashless offers convenience, but reimbursement provides flexibility in hospital choice.

Things to Keep in Mind When Filing a Claim

Always check network hospitals in advance

Before hospitalisation, confirm whether your chosen hospital is on the insurer’s cashless network.

Keep documents ready for reimbursement claims.

Maintain all medical bills, discharge papers, and prescriptions in one place.

Understand policy exclusions before hospitalisation

Go through waiting periods, exclusions, and limits carefully to avoid shocks during settlement.

ManipalCigna Advantage in Claims

• Wide network of cashless hospitals across India: ManipalCigna offers access to thousands of hospitals across the country for quick and easy cashless claims.
• 24/7 claim assistance and faster settlement: Round-the-clock support teams help policyholders resolve queries and speed up approvals.
• Transparency and digital claim tracking: Digital platforms and notifications keep customers updated on claim progress.
• Example: How ManipalCigna’s Sarvah Uttam plan simplifies claims: This plan offers inclusive coverage and a simplified claim flow, ensuring policyholders have minimal hassle in both cashless and reimbursement processes.

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