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, if you do not choose a network hospital for treatment, your claim is not automatically rejected. The difference is that at a network hospital, which is tied up with your insurance provider, you can avail treatment on a ‘cashless’ basis, where the insurer settles the approved amount directly with the hospital.
On the other hand, at a non-network hospital, you pay the bills upfront and then submit them to your insurance provider, who reimburses the admissible amount as per your policy terms. Here, you first need to pay out of your pocket, the settlement takes longer, and you need to collect and submit all the paperwork to your insurer after the patient is discharged.
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 is a formal request made by the policyholder or insured person to the insurance company to cover the medical expenses incurred. When hospitalisation occurs, filing a claim with the insurance company or through its TPA (Third Party Administrator) is essential to access the benefits under the policy.
Whether the claim is cashless or reimbursement depends mainly on whether the treatment is taken at a network or non-network hospital. Both processes aim to ensure that the insured receives the right medical treatment while reducing financial stress.
Types of Health Insurance Claims
Reimbursement Claims
When a policyholder opts for a hospital that is not part of the insurer’s network, they pay the 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 the discharge summary, prescriptions, and medical bills.
- These documents are submitted to the insurer or TPA along with the claim form.
- After verification, the insurer transfers the approved amount directly to the policyholder’s bank account.
Advantages and limitations of reimbursement claims
Reimbursement claims offer the 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
In cashless claims, the insurance company settles the approved amount directly with the network hospital, so you do not have to arrange large amounts of money for your treatment.
How cashless hospitalisation works
- The policyholder chooses a network hospital.
- The hospital sends a pre-authorisation request to the insurer.
- After approval, the insured is admitted and treated.
- On discharge, the bill is settled between the insurer and the hospital.
Benefits of cashless claims
Your savings stay protected, as you do not need to arrange large sums of money during a health emergency. The entire process from admission to discharge is faster and more convenient for the patient.
How Do Health Insurance Claims Work?
General process flow
- Visit a hospital for treatment.
- Submit your policy details and ID proof.
- The hospital or insured notifies the insurer or TPA.
- The claim is reviewed and settled on either a cashless or reimbursement basis.
ManipalCigna’s streamlined claim process for customers
ManipalCigna has simplified claim management with a wide hospital network, round-the-clock support, and digital tracking tools. This helps make approvals faster, reduces paperwork, and minimises delays for customers.
Claim Process in Detail
For Reimbursement Claims
Documents required
Key documents include the claim form, discharge summary, prescriptions, diagnostic reports, pharmacy bills, and original hospital bills.
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, informing the insurer about the hospitalisation as per the timelines mentioned in the policy, and submitting complete documents after discharge.
For Cashless Claims
Network hospital admission process
The insured must select a network hospital, show their health card or policy details at the hospital’s insurance desk, and request admission under cashless coverage.
Pre-authorisation request
The hospital sends the estimated treatment costs and medical details to the insurer for approval. The insurer reviews the request and communicates its decision to the hospital.
Final settlement after discharge
The insurer verifies the final bill against the pre-authorisation and pays the approved amount directly to the hospital. The patient may need to pay only for non-payable items, such as certain consumables, and any applicable co-payment or deductible.
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 do not want to pay large bills upfront.
- Based on preference (convenience vs flexibility): Cashless offers convenience, while 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 part of the insurer’s cashless network.
Keep documents ready for reimbursement claims
Keep all medical bills, discharge papers, and prescriptions in one place.
Understand policy exclusions before hospitalisation
Go through the waiting periods, exclusions, and limits carefully to avoid surprises during settlement.
ManipalCigna Advantage in Claims
- Wide network of cashless hospitals across India: ManipalCigna offers access to a wide network of hospitals across the country for quick and easy cashless claims.
- Round-the-clock claim assistance: Dedicated support teams help policyholders resolve queries and assist with approvals.
- Transparency and digital claim tracking: Digital platforms and notifications keep customers updated on their claim progress.
FAQs
What should I do if my cashless claim is denied?
If your cashless request is denied, ask for the reason for denial. You can still pay the hospital bills and file a reimbursement claim later with all the required documents, which will be assessed as per your policy terms.
How long does ManipalCigna take to process claims?
Cashless requests are processed quickly once the hospital submits the pre-authorisation request. Reimbursement claims are processed after all the required documents are received, and the time taken depends on the completeness of the documents and verification.
What is the difference between cashless and reimbursement claims?
Cashless claims are settled directly between the insurer and the network hospital, whereas in reimbursement claims, the insured pays first and is reimbursed the admissible amount later.
How do I file a cashless claim with ManipalCigna?
Select a network hospital, provide your policy details and ID proof, and the hospital will send a pre-authorisation request to ManipalCigna for approval.
What documents are required for a reimbursement claim?
You need the claim form, discharge summary, prescriptions, diagnostic reports, pharmacy bills, and original hospital bills. Additional documents may be requested depending on the treatment.
Can I get cashless treatment at any hospital in India?
Cashless treatment is available at hospitals in ManipalCigna’s network. For treatment at other hospitals, you can file a reimbursement claim.
