What cashless means
In a cashless claim, the insurer or its TPA (third party administrator, a company that handles claims for insurers) pays the hospital directly for covered expenses. You pay only for what isn’t covered, such as items your policy excludes, your co-pay, or amounts above your limits.
Step 1: Find a network hospital
Cashless is available only at hospitals that have a tie-up with your insurer, called network hospitals. The list is on the insurer’s website or app, and often with your health card. Check it now, before an emergency, and note the ones near you in Rajula, Amreli or wherever you would go for treatment.
Step 2: Planned or emergency admission
- Planned admission (like a scheduled surgery): inform the insurer or TPA in advance, as your policy requires, and get pre-authorisation before you are admitted.
- Emergency admission: get treatment first. Then you or the hospital should inform the insurer as soon as possible, within the time your policy states.
Step 3: The pre-authorisation form
At the hospital’s insurance or TPA desk, you fill in the patient’s part of the pre-authorisation form, and the treating doctor fills in the medical details. The hospital sends it to the insurer or TPA. They review it and reply with an approval for an amount, a request for more information, or a refusal. Approval of the first amount isn’t the final settlement; the final bill is checked at discharge.
Documents to keep ready
- Health card or policy number
- Photo ID and address proof of the patient, such as Aadhaar
- The doctor’s note or prescription recommending admission
- Earlier medical reports for the illness, if any
- KYC documents, if the insurer asks for them
What isn’t covered
Even in a cashless claim, some costs come out of your pocket. Common ones are non-medical items like gloves, toiletries and registration charges, your co-pay share, the extra cost of a room above your room rent limit, and anything excluded in the policy wording. Ask the hospital desk early what you are likely to pay.
Step 4: Discharge
When the doctor decides on discharge, the hospital sends the final bill and discharge summary to the insurer or TPA for final approval. This can take some time, so ask the hospital to start the paperwork early on the day of discharge. Check the bill, pay the amount that isn’t covered, sign, and collect copies of all papers.
When cashless isn’t possible: reimbursement
If the hospital isn’t in the network, or cashless is refused, you can pay the bill yourself and then claim a reimbursement. Submit the claim form with original bills, payment receipts, the discharge summary, reports, prescriptions and a cancelled cheque, within the time limit in your policy. Keep photocopies of everything.
If your claim is delayed or denied
First, ask for the reason in writing. Often it is just a missing document. If you still disagree, follow these steps in order:
- The insurer’s grievance cell: write to the insurer’s grievance officer with your policy number, claim number and documents.
- IRDAI Bima Bharosa: if the insurer doesn’t reply in time or you’re unhappy with the reply, register a complaint on Bima Bharosa.
- Insurance Ombudsman: if the insurer has rejected your complaint or not resolved it, you can approach the Insurance Ombudsman, a free and independent forum.
For policies placed through us, our claim support team helps with forms and follow-ups. See our grievance redressal page for full details.