What is a cashless network hospital?

With the ever-rising cost of healthcare, a number of individuals are buying health insurance policies as a way to cut down on their healthcare bills. While health insurance is a boon for those who are looking a quality medical care, having to pay the hospital for treatment could prove to be expensive. While the amount spent would be reimbursed, the policyholder would still be required to make the initial payment, which could amount to a significant sum.

Enter cashless claims. A cashless claim is one where the policyholder is not required to pay for treatment or medical procedures that are covered under the health insurance policy purchased. The insurance company would directly settle the bill with the hospital in question.

This service makes healthcare even more affordable and accessible, as the policyholder does not have to worry about having to pay a hefty sum of money at the time of being admitted or during the course of treatment.

This kind of facility, however, is only available at network hospitals, or partner hospitals.

A network hospital is one with which the insurance company has an agreement with, which allows the policyholders to receive medical treatment on a deferred payment basis.

How do cashless network hospitals work?

A cashless network hospital works similar to a regular or non-partner hospital for the most part. Policyholders can visit a network hospital and receive medical care without having to make a payment to the hospital. This includes the admission charges, room charges, cost of treatment, doctor/specialist fees and ambulance cost.

The medical bills would be settled against the Sum Assured that was opted for at the time of purchasing the health insurance policy.

All the above would be borne by the insurance company (provided the treatment sought is covered by the policyholder’s insurance policy).

The policyholder merely has to notify the hospital that the treatment would be under the cashless treatment facility and produce identification, such as the policy document or an identity card issued by the insurer.

Advantages/benefits of cashless network hospitals

When an individual is admitted to hospital for any procedure, whether routine or emergency, it is a stressful time for the family and the individual himself/herself. With most hospitals insisting on periodic clearance of bills, families have to scramble to pay astronomical bills while ensuring the individual receives quality medical treatment.

With cashless medical facilities, all bills will be paid directly by the insurance company once the treatment has been completed.

In the event that the policyholder is to be admitted to hospital away from home, hospitals part of the insurance company’s network across the country can be used to treat the policyholder without having to settle bills or make any payments.

In the event of an emergency medical procedure or if the policyholder is facing financial problems, cashless network hospitals are a saving grace since the policyholder is assured of quality medical care without the need to pay for the treatment.

How to File A Claim Through a Cashless Network Hospital

In the event that a claim is to be filed, the following procedure is to be followed:

• In the case of planned surgeries, the insurance company is to be notified so as to authorise the cashless treatment.
• In the event of an emergency surgery or procedure, the insurance company is to be notified within 24 hours of the policyholder being admitted to hospital.
• In certain cases, the policyholder is given an identity card, which can be used to avail of the cashless facility at any of the partner hospitals.
• The policyholder can undergo treatment at the partner hospital without having to pay.
• The insurance company would then send the policyholder a summary of the charges, and any exclusions would have to be paid for by the policyholder.

List of Procedures Covered by Cashless Network Hospitals

All procedures requiring a hospital stay over 24 hours are covered under cashless hospital claims.

The list of day care facilities (that require a stay of less than 24 hours) covered are mentioned below:

• Operation on eyes- this includes the following procedures:
  • Cataract operation.
  • Eyelid incision.
  • Corneal incision.
  • Tear duct operations.
  • Removal of foreign body.
  • Corrective surgery for entropion, ectropion.

• Operations on the ear:
  • Stapedotomy.
  • Stapedectomy.
  • Operations on the auditory ossicles.
  • Operations on the middle ear.
  • Tympanoplasty.
  • Reconstruction of the middle ear.
  • Incision of the inner ear.
  • Other operations on the inner ear.

• Operation on nose and sinus:
  • Operation on nasal concha.
  • Nasal sinus aspiration.
  • Other operations on the nose.
  • Foreign body removal.

• Operations on the tongue:
  • Reconstruction of the tongue.
  • Glossectomy.
  • Other operations on the tongue.

• Operations of the bones:
  • Ligament tear and meniscus tear surgery.
  • Dislocation surgery.
  • Orthopaedics and trauma surgery.
  • Fractures and sutures on tendons.
  • Other joint and bone surgery.

• Operations on skin and subcutaneous tissue:
  • Chemosurgery to skin.
  • Skin transplantation and restoration.
  • Excision of diseased skin and subcutaneous tissues.
  • Incisions to skin and subcutaneous tissue.

• Operations:
  • Coronary angiography.
  • Haemodialysis.
  • Lithotripsy.
  • Radiotherapy (for cancer).
  • Chemotherapy.

• Operations on the face:
  • Plastic surgery to the mouth.
  • Incisions to the mouth, jaw and face.
  • Other operations to the mouth and face.

Surgical procedures and treatments in the digestive tract as well as male and female reproductive organs are also covered.

Exclusions Under Cashless Network Hospital Services

While a number of procedures and treatments are treated under cashless cover, there are a list of exceptions under which the insurance company will not pay for treatment. These are listed below:

• Hospitalisation due to war, chemical or biological weapons or radiation.
• Treatment arising out of self-injury, self-harm or suicide when sane or insane.
• Hospitalisation arising out of abuse of psychotropic substances or alcohol.
• Treatment due to complications arising out of HIV/AIDS, unless specified in the policy document.
• Congenital diseases and mental disorders as defined in the policy brochure.
• Items of personal comfort and convenience.
• Additional costs like special diets.

Case example

Mr. X is a 45 year old man who purchased an individual health insurance policy and chose a Sum Assured of Rs.5 lakh. He was recently admitted to hospital for an emergency appendectomy, and chose a network hospital to undergo his procedure. The total cost of the procedure and care amounted to Rs.70,000, including the hospital stay. Mr. X had recently paid off his home loan and was short of ready cash. However, by opting for cashless medical care at a network hospital, he did not have to pay the hospital to settle the bills, as they were settled directly by the insurance company.

The Rs.70,000 was deducted from his Sum Assured, leaving him with Rs.4,30,000 to cover the cost of other medical expenses in future.