Even a cashless health insurance claim may require you to pay; Here’s why

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Published: February 9, 2020 11:32 AM

A common misconception that most policyholders believe is that if their total treatment cost is less than the sum insured, it will be covered by the insurer. That's not how it works;

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While making a health insurance claim, in case of a health insurance policy with the medical reimbursement option, the policyholder needs to show the hospital bill to the insurer and the amount is reimbursed. However, in the case of a cashless claim, the insured does not have to pay the hospital bills as the insurance company reimburses the same directly to the hospital.

Though this is how it should work, that is not the case always.

In fact, with the cashless claim option, most policyholders think they are not liable to pay anything against treatment if they are pre-authorized for the cashless option. However, that’s not the case, as the insurance company makes a few deductions.

Be it is a cashless claim or a reimbursement claim, know the benefits that you are entitled to. Read the terms and conditions carefully, so that a deduction does not come as a disappointment later.

Find out what you are required to pay in a cashless claim option:

Exclusions: Every medical expense is not covered by insurance policies. Hence, there are deductions due to non-admissible items or services when making a claim. For instance, services such as registration charges, medical record fees, admission fees, insurance processing fees, etc. are also not covered.

Room rent limit: Room rents are capped with most insurance policies. With this, upper-limit is applied on the room rent beyond which the insurance company is not liable to pay for the policyholder. Hence, if during hospitalization you choose a room whose rent exceeds this upper-limit, a proportionate charge will be applied to all the treatment-related services.

For instance, Aparna is eligible for a semi-private room with rent up to Rs 3,000. Now if she chooses to stay in a deluxe room with rent Rs 6,000, she will end up bearing 50 per cent of the total cost because of the proportionate deduction in the final claim settlement. This is because the insurance company will not cover the increase in the bill due to the room selection.

Co-pay: Co-payment is an insurance policy decreases the premium out pay. With the Co-pay option, the policyholder is liable to pay a certain percentage of the total claim amount. This is applied to the dependents of the policyholder such as spouse, children, and parents. Also, for a senior citizen policyholder co-pay is also applied to every claim he/she makes.

Sub-limit on treatments: A common misconception that most policyholders believe is that if their total treatment cost is less than the sum insured, it will be covered by the insurer. What they don’t understand is that under a policy almost every treatment has a limit applied to it. Hence, if the treatment cost exceeds the limit, the policyholder will have to pay the difference.

For instance, if Aparna is insured under a policy with a sum insured of Rs 5 lakhs, usually under a policy normal delivery charges and C-section delivery charges up to Rs 30,000 and Rs 50,000 respectively are covered. Hence, if the maternity expenses exceed the specific amount, Aparna will have to pay the difference out of her pocket. This is applicable despite having a sum insured for up to Rs 5 lakhs.

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