Cashless Claim or Reimbursement Claim

The uncertain times we’re living in, the ongoing pandemic, and our lifestyle necessitates health insurance purchase. Group health insurance provides financial cover for the insured and their loved ones in any hospitalization expense. To aid people with the same, numerous insurers are offering a different mix of policies, providing comprehensive coverage and a variety of advantages that can help during financial emergencies.

There are various reasons to choose a policy, from coverage to procedure and network of the insurer. Another factor that one must carefully understand while selecting a policy is how claim settlement is offered by the insured.

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What is a Cashless Claim?

A cashless claim is a type of health insurance claim where you receive treatment at a network hospital without making immediate out-of-pocket payments. Instead, the hospital sends the costs directly to the insurer for settlement.

To avail of this, you simply go to a hospital that's part of your insurer's network, present your health e-card and identification proof. However, keep in mind that you need to obtain prior approval from your health insurer. For planned hospitalizations, this should be done at least 72 hours in advance. For medical emergencies, approval should be sought within 24 hours of admission.

Once you've received your treatments, submit the necessary claims forms to the third-party administrator, or TPA (the intermediary between the hospital and your health insurer). From there, the insurer takes over and handles your claims.

Read More: TPA in Health Insurance

What is a Reimbursement Claim?

A Reimbursement claim is a type of health insurance claim where your choice of hospital isn't restricted to your insurer's cashless network. You can receive treatment at any hospital, bear the initial costs, and subsequently file a claim with your insurer to get these expenses reimbursed.

To initiate this process, you must submit all relevant documentation, including hospital bills, prescriptions, and medical records. These documents must be reviewed and approved by the insurer, a process that may extend the time it takes to settle the claim. So, while this method offers greater flexibility in choosing your healthcare provider, it may require a bit more patience for the claim to be processed.

Difference Between Cashless and Reimbursement Claims

Differences	Cashless Claims	Reimbursement Claims
What is it?	A cashless claim involves visiting a hospital within the insurer's network, where the health insurer directly settles your bills.	You bear the upfront cost of hospital bills after treatment. You then present these bills and relevant medical documents to your insurer for claim approval.
Claim Process	The insured must inform the insurance company in advance and file a claim. The insurance company directly settles hospital bills.	The insured files a reimbursement claim post-treatment with all bills, original and verifiable receipts for treatment.
Claim Settlement	The insurance company directly settles all treatment expenses within policy parameters.	The insured pays hospital bills first, then files for claims to get reimbursed.
Claim Approval	Should get approval 72-hours before in case of planned hospitalization, and within 24-hours in case of a medical emergency.	No Claim Approval Required
Time Taken	Generally quicker when compared to reimbursement.	May take longer as it requires processing of reimbursement claims.
Documents Required	Need to fill in the required form given by the TPA at the hospital. You don’t need to submit bills or other documents.	You need to submit your health invoices, including medical bills, doctor’s prescriptions, and any other relevant information.
Flexibility	The insured must opt for treatment at a hospital within the insurer's network.	Treatment can be availed at the hospital of the insured's choice. Verification of treatment is required to claim reimbursement.
Hospital Availability	Can only be availed at a hospital in the insurer's network.	Treatment can be availed at any hospital within the scope of the insurance.

Network of Hospitals

Cashless claims can only be availed at the facility on the insurers' network. The insurance company covers all the expenses within the policy parameters when intimation is provided by the insured as per the set guidelines.

For reimbursements, the insured can avail of the treatment at any hospital if the treatment is within the scope of the insurance. On filling in all the necessary documentation and successfully verifying the same, the insurer's claim gets approval.

Payment for Treatment Expenses

On availing, cashless benefits, the insured can avail of the treatment without shelling out cash for treatment expenses. All the costs incurred for the insurance company directly settle treatment until the same is within the scope of the insurance policy chosen.

For reimbursements, the insured must pay the hospital bills and then file for claims in the required format with the insurance company. Upon successful completion of the claim settlement process, the insured gets reimbursed for the claimable expenses.

Claim Process

For choosing the cashless option, the insured must inform the insurance company in advance and file for a claim, after which the insurance company directly settles hospital bills.

A reimbursement has to be filed post-treatment with all the bills, original and verifiable receipts for treatment.

Time

Cashless claims are generally quicker when compared with reimbursement.

Flexibility

To avail of cashless benefits, the insured has to opt for treatment at a hospital within the insurance company's network.

Reimbursement claims can be made for treatment availed at the hospital of choice by the insured, and then with verifiable proof of treatment, the same can be claimed.

When it comes to choosing a policy based on benefits and ease associated, insurance offering cashless benefits certainly has an edge. Hospitalizations are when one already has so many burdens and stress; adding financial stress can be a bit much. A cashless option enables the insured to avail of the treatment with a lot more ease.

Health Insurance policies have various features, and choosing a policy based on merits requires one to use expert help. They are helping hands that can make you understand the minute difference between the policies and fine-tune the selection process to arrive at a solution.

An organization wishing to provide health cover to its employees requires an expert service that can enable them to devise a plan to arrive at a solution best fitted to the organization. This solution should follow the parameters along with high-quality insurance. Plum Insurance provides a mediclaim policy with no hidden costs, no surprises, and no out-of-pocket expenses.

Benefits of using Plum Insurance

Dashboard: A dashboard from where employers can access all the required information and make the necessary modifications as and when required.
Chat-based support: Plum Insurance provides a claim filing facility over WhatsApp that makes usability an excellent experience.
Flexibility: The Plum Insurance dashboard can be used over any device, which provides employers greater flexibility.

When there is a need to understand the difference between policy terminology and the solution that will best fit, an expert like Plum can help the corporation do wonders in their health plans. Plum Insurance adds to policy features by providing additional wellness facilities from time to time. These facilities allow the employees to maintain a healthier course through optimal consultation facilities and therapist facilities.

Let's give our team the cover they deserve.

FAQs

1. What is a cashless claim?

The cashless claim is a health insurance feature, which enables the insured to get treatment at an insurance network hospital without any upfront payment.

2. How do I claim cashless benefits?

To avail of cashless benefits at a network hospital, file your claim along with a health insurance card and the required paperwork. The person handling insurance at the hospital help desk will coordinate for the pre-authorization.

3. How do I claim Insurance reimbursement?

After completing your treatment, you must file for reimbursement within the stipulated time and format. For reimbursements, all the medical papers and certificates related to the treatments must be furnished. On verification of the same by the insurance company, claims get approval.

4. Which is better for the insured cashless or reimbursement option?

The whole purpose of buying health insurance is to lessen the financial burden in times of need. As a cashless option provides more excellent relief over reimbursement, the cashless option is preferable.

5. What can an Insured do to make the claim process easier?

Insured can file for claims as quickly as possible to ensure a smooth claim settlement process. Even in a cashless claim, a pre-authorization can be taken as early as 15 days before the treatment procedure.

6. What specific documentation is required for cashless and reimbursement claims, and are there any differences in the documentation needed for each type?

For cashless claims, you need your health insurance card and pre-authorization form from the hospital. For reimbursement, submit detailed bills, prescriptions, and discharge summaries. Therefore, the primary difference lies in the pre-authorization for cashless claims and the detailed bills for reimbursements.

7. How does the claim settlement process vary if the treatment exceeds the insurance policy's coverage limits?

If treatment costs exceed coverage limits, you're responsible for the difference. In cashless claims, the insurer directly informs you of the payable amount. For reimbursements, you'll first pay, then claim up to your limit. Thus, awareness of your policy's limits is crucial to manage out-of-pocket expenses.

8. Can an insured switch between cashless and reimbursement claims for different medical treatments or hospitalizations, or are they locked into one type of claim process after choosing a policy?

Yes, insured individuals can choose between cashless or reimbursement claims for different treatments under the same policy. Flexibility is a key feature, allowing you to opt for cashless at network hospitals and reimbursement elsewhere. Therefore, your choice of claim type can adapt to circumstances, ensuring ease and convenience.