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Network vs Non-Network Hospitals in Health Insurance

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Jul 03 2023

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A health insurance policy provides you coverage against hospitalisation expenses. However, how the hospitalisation expenses are paid depends on which hospital you got admitted to. If it is a network hospital, the insurer will settle the bill directly with the hospital. However, if it is a non-network hospital, you must pay the bill from your pocket and later get reimbursed by the insurer. In this article, we will understand the network and non-network hospitals, their differences, and which one you should prefer for treatment.

What are network hospitals?

A network hospital is one that the insurance company has a collaboration with. Insurance companies build a hospital network by empanelling hospitals. ManipalCigna Health Insurance has a vast network of 8500+ hospitals. An insured person can get admitted to a network hospital and avail of the cashless treatment facility.

At the time of admission, the insured has to submit the policy details (copy of health ID card or policy number) along with the KYC documents. The hospital contacts the insurance company or their Third Party Administrator (TPA) and takes the authorisation for cashless treatment. The insured can avail of the treatment. At the time of discharge, the hospital submits all the details to the insurance company/TPA for final approval. It may include admission details, treatment bills, diagnostic test reports, prescriptions, doctor's reports, discharge summary, etc.

Once the insurance company approves the final amount, the insured must pay the balance, if any. The insured has to bear the following expenses from their pocket:

a) Consumables: The insured has to pay certain expenses, such as consumables and others, that are usually not covered under insurance.

b) Co-payment: If a co-payment clause exists, the insured has to pay their share.

c) Deductible: If there is a deductible, the insurance company will pay the amount after reducing the deductible amount.

d) The bill amount is higher than the approved amount: If the hospitalisation bill is higher than the package amount approved by the insurance company, the insured has to pay the difference.

Even though the insured may be required to pay certain expenses from their pocket, availing treatment at cashless hospitals is preferable. Network hospitals may provide discounts on certain treatments to insured patients as part of their package deal with the insurance company.

What are non-network hospitals?

As the name suggests, a non-network hospital is not a part of the insurance company’s hospital network or is not empanelled. Either the insurance company has still not collaborated with the hospital, or they have not yet reached a mutually acceptable arrangement.

When the insured avails of treatment at a non-network hospital, the cashless treatment facility is not available. The insured can make a claim on a reimbursement basis. The process works as follows:

a) The insured has to inform the insurance company about the non-network hospital admission and avail of the treatment

b) At the time of discharge, the insured must pay the hospital bill and collect all the documents.

c) The insured must submit the duly filled claim form and all the required documents to the insurance company.

d) The insurance company will verify the documents, and if they are in order, they will reimburse the amount in the insured’s bank account. If there are queries or any document(s) are missing, the company will inform the insured accordingly. 

Network vs non-network hospital

Some of the differences between a network and a non-network hospital include the following:

Feature

Network hospital

Non-network hospital

Empanelment

The insurance company has empanelled it and is part of the hospital network.

The insurance company has not empanelled it, and is not a part of the hospital network.

Admission

The insured can inform the insurance company before admission in case of planned hospitalisation. For emergency admission, the insured can inform within 24/48 hours. The insurance company will authorise treatment for up to a specified amount.

The insured can inform the insurance company within 24/48 hours of admission.

Treatment and bill payment

Insured can avail of cashless treatment. At the time of discharge, the insurance company will settle the bill directly with the hospital. The insured needs to pay the amount that is not covered. The settlement of the bill happens in a couple of hours, and you can leave, although the insurance company may pay the hospital later. There is less paperwork.

At the time of discharge, the insured will have to pay the bill from their pocket. Later, they can claim reimbursement from the insurance company. It involves a lot of paperwork as the entire set of documents has to be submitted. The reimbursement of the amount may take a couple of days to a couple of weeks.

Convenience and preferred option

Getting treatment at network hospitals on a cashless basis is convenient for the insured. For planned hospitalisation, you can take authorisation in advance. Hence, it is the preferred option.

As the cashless treatment option is not available, it may cause temporary inconvenience to the insured. They have to arrange the funds for hospitalisation bill payment. Hence, it is not the first choice. Although in case of emergency hospitalisation, it will be preferred if it is the nearest hospital available.

Inclusion/exclusion

Insurance companies review their hospital network from time to time. Today, a hospital that is a part of the network may get excluded in the future.

A hospital that is not a part of the network today may get empanelled in the future.

 

Factors to consider

At the time of buying a health insurance policy, an individual should consider the following factors:

a) Network size: Before purchasing a health insurance policy, check the size of the hospital network of the insurance company. The bigger the hospital network, the better. ManipalCigna Health Insurance Company has a vast network of 8500+ hospitals providing cashless treatment facilities.

b) Hospitals in your area: Check whether the hospitals in your area are a part of the insurance company’s hospital network. If you prefer a specific hospital, whether or not located in your area, check whether it is a part of the hospital network.

c) Addition/deletion to the network: Insurance companies regularly review their hospital network. They are making all efforts to increase their network by continuously adding more hospitals. So, if a hospital is not a part of the network today, it may get empanelled in future. Similarly, if a hospital is already a part of the network, it may get excluded in future. Hence, before getting admitted to a hospital, always check first whether it is a network hospital to avoid unpleasant surprises after admission. You can check the list of network hospitals on the company website, mobile app, or customer care.

Choosing between a network and non-network hospital

Most people will prefer a network hospital as it provides convenience with a cashless treatment facility. However, non-network hospitals are also equally important. There may be circumstances when emergency hospitalisation is required, and the nearest available hospital is a non-network hospital.

There can be an instance where the specific doctor from whom you want to avail treatment is associated with a non-network hospital or a specific treatment you want to avail is available at a non-network hospital. In such scenarios, you can avail of the treatment at the non-network hospital and get the cost reimbursed. So, while network hospitals are preferred, non-network hospitals are also equally important. The decision of which one to avail of all depends on your circumstances.

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