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Cashless vs Reimbursement Claims in Health Insurance

A health insurance policy proves to be the most useful when you make a claim under the plan. Medical contingencies have a way of sneaking up on you and when you have a health insurance plan handy, you do not have to worry about getting your claims settled. However, many individuals fear to make a claim in their health insurance policies because they don’t know the process. Do you? Making a health insurance claim is easy if you know the correct and chronological steps involved in it. That is why it is imperative to understand the claim settlement process of a health plan you are considering to buy. A health insurance claim can be settled through a cashless facility or through reimbursement. 

Do you know about them? 
What is cashless claim? 

A cashless claim settlement facility is one where the insurance company directly settles your medical bills with the hospital. You are, thus, spared the burden of footing your bills yourself. Most health insurance plans provide cashless claim settlement facility provided you avail treatments at a Preferred Provider Network (PPN). A Preferred Provider Network is a hospital which is tied-up with the insurance company. Taking treatments in a PPN
would only qualify for cashless claim settlement.
Reimbursement claim Though many health insurance policies promote cashless claim settlement, there are a few plans where the claim is settled through reimbursement. Moreover, if, in a cashless health plan, you do not avail treatments in a networked hospital, your claim would be settled through reimbursement. So, what is reimbursement? Under a reimbursement claim, you have to first foot your medical bills and avail hospital treatments. After you are discharged, you have to submit all your relevant medical bills along with the discharge summary and get the expenses reimbursed from your health insurance provider.

Let us understand their differences:
Cashless claimReimbursement claim
You do not have to pay any medical costs yourself. The insurance company settles the bills directly with the hospital.You have to bear your medical costs first. Then the costs are reimbursed after you are discharged from the hospital and you submit the necessary bills.
You have to take treatment only in a network hospital.You can take treatments in any hospital.
The claim is settled instantly.Reimbursement claims take time.

Which one is better? Well, this one is a no-brainer. A cashless claim settlement process is the best as it spares you from any financial burden. Under a reimbursement claim, you have to pay the medical bills which can create a financial crisis. A cashless claim spares you this hassle and is the best. Process of making cashless and reimbursement claims Even though cashless claims are the best, you must know the claim process under both methods. After all, in case of an emergency, you might end up being hospitalized in a non-network hospital and avail reimbursement claim settlement. So, here are both processes for your knowledge: Cashless claim process
  • In case of a planned hospitalization, you should inform the insurance company well in advance. Insurance companies might engage the services of Third Party Administrators (TPA) for handling the claim process or have an in-house claim settlement department. TPAs are intermediaries between you and the insurance company and help in processing your claim.
  • If on the other hand, your hospitalization is emergent, the insurance company or the TPA should be informed at the earliest. Insurance companies have a time limit of such intimations and you should stick with the limit for getting your claim settled easily.
  • When you inform the company or the TPA, you would get a pre-authorization form. You are required to fill this form and submit it so that you can get approval for your treatments and the company can settle the bills directly.
Reimbursement claim
  • During your treatment, you should meet all the expenses and collect each and every medical bill pertaining to the treatment.
  • When you are discharged from the hospital, collect the Discharge Certificate or the Discharge Summary from the hospital.
  • Submit the Discharge Certificate or Summary along with the medical bills to the insurance company.
  • The company would scrutinize the bills and reimburse you for the claim incurred.
So, now you know the difference between a cashless claim and a reimbursement claim. Both are different and have different processes. A cashless claim is better and you should choose a plan which offers this claim facility. You should also follow the correct process to get your cashless claim settled. So, the next time you face a claim, don’t be scared. Understand the processes and get the claim settled easily.

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