How Cashless Medicalance Works – Forbes Advisor INDIA


The only reason we buy health insurance is for the financial help it provides when any medical emergency occurs. And, after going through a stressful hospitalization, the insured expects that there will be no hassle in settling hospital bills and that all bills will be settled directly between the insurance company and network hospital.

Cashless insurance policy offers the benefit of immediate access to healthcare needs without worrying about paying hospital bills and treatment costs. That is why, majority of insurance companies have started providing a lot of benefits on cashless health insurance policies.

Read on to find out what the cashless health policy means, how it works and how it benefits policyholders in times of need.

What do you mean by cashless health insurance?

Simply put, under cashless health insurance, all medical bills are paid directly by the insurer and not by the insured. The only condition here is that the total medical or hospitalization costs must not exceed the sum insured and that the hospital selected must be a network hospital.

This type of insurance is extremely beneficial in the event of a planned or sudden medical emergency. As in the case of a cashless policy, the insurance company covers all expenses related to hospitalization and treatment costs in advance and thus leaves you more time to concentrate on other matters. important such as the organization of treatment or hospital admission formalities.

Key Features of Cashless Health Insurance

  • Medical expenses are covered directly by the insurance company.
  • To benefit from this facility, the patient must be admitted to one of the hospitals in the network.
  • Always keep a copy of all required documents such as diagnostic reports, medical bills, discharge summary and claim form.
  • The insurance company covers the medical costs, if they fall within the limit of the sum insured. Any amount that exceeds the sum insured, the policyholder is obliged to pay the excess amount.
  • Expenses beyond the sub-limits predefined by the health insurance policy or items not covered by the policy must be paid by the insured.

How does cashless health insurance work?

Health insurance providers partner with different hospitals across the country after reviewing their quality, reputation, rates, and procedure coverage. These are called in-network hospitals, which have been vetted by insurance companies after their extensive background checks.

Cashless insurance is only available at these network hospitals. So, when you get admitted, you will still have the option to get admitted to the network hospitals to take advantage of the cashless facilities. For this, there is an assigned APT (Third-Party Administrator) who are fully responsible for coordinating with the Hospital and settling your claims with the insurance company. This TPA is also responsible for approving or denying your cashless insurance claims.

However, the insured can also be treated in a hospital outside the network. But, in this case, the policyholder must first pay the bills and then seek reimbursement from the insurance company.

List of Top Insurance Companies Providing Cashless Health Insurance in India

When is a cashless health insurance claim rejected?

Cashless application in health insurance may be rejected for the following reasons:-

  • If the patient is admitted to an out-of-network hospital that has no connection to the insurance company.
  • If the pre-authorization claim request is not shared in time.
  • If the medical condition for which a cashless claim was requested is not covered or the waiting period has not expired.
  • The claim form or policy document contains incorrect information.
  • If the policy has expired, any claims filed during this period will not be accepted.

Types of Cashless Health Insurance in India

Individual Cashless Insurance: The cashless insurance policy covers all the medical expenses of the primary insured who in turn can enjoy the benefits of cashless hospitalization in the easiest way.

Cashless family insurance: This type of cashless insurance covers the whole family under a single premium policy. Here, cashless benefits can be used by all insured family members, including the main policyholder. As the coverage is split among all family members, the sum assured is usually higher compared to the individual plan.

Senior health Insurance: This type of cashless policy provides cashless benefits to seniors. Those covered under this policy receive cashless benefits for expenses such as ambulance costs, hospital bills and for much more extensive coverage as per the policy.

Benefits of cashless health insurance

Access to rapid treatment: When your cashless healthcare policy is in place, it is very easy to access immediate treatment without worrying about exorbitant hospital bills. All you have to do is notify the hospital helpdesk within 24 hours in the event of an emergency and within 48 hours in the event of scheduled hospitalisation.

Full Benefits: A cashless health insurance policy is a very convenient way to use the health insurance policy. One can also enjoy all the comprehensive benefits from paying medical bills to fully covering ambulance costs and more.

Enjoy coverage while traveling: Medical problems can also arise while travelling. But if you have your cashless insurance policy in place, you can easily qualify for treatment at any of the in-network hospitals across the country.

Tax savings: You may also enjoy tax advantages, as premiums paid for the cashless health insurance policy for families, individuals or seniors are exempt from tax under Section 80D of the Act. income tax.

Factors to Consider Before Choosing a Cashless Health Insurance Policy

List of hospitals in the network: Before choosing a cashless health insurance policy, always check the list of in-network hospitals with which the insurance company has a connection. Hospitals that are near or near your locality should be included in the list, so that you can easily avail cashless treatment in case of medical emergency.

Coverage of the insured capital: The sum insured of the cashless health insurance policy must be sufficient to cover you and your family in the event of a medical emergency.

Co-pay and other sub-limits: Always keep an eye out for sub-limits and co-pay clauses. The co-payment is the percentage that the policyholder has to bear by the policyholder and not by the insurance company.

Waiting time: Remember that any illness or treatment would only be granted cashless facility if it does not fall within the waiting period. Choose the policy with the least waiting period.

Daycare procedures: Cashless policies also cover a lot of custodial procedures. Make sure to select the plan that has a large number of daycare treatments.

Cashless Complaints Procedure

In order to qualify for medical treatment under a cashless policy, one must complete the pre-authorization form which is available either from your TPA or from the hospital’s insurance office. The completed form is then sent to the relevant TPA who approves or disapproves the request in these two circumstances:

Planned hospitalization: In the case of a planned hospitalization, you must inform the network hospital within 48 hours of the actual hospitalization. The process was to complete the claim form and submit it to your TPA on time. This will then be checked and verified, so please do not fill in wrong information. Once approved, the amount claimed will be paid directly by the insurance company and the hospital.

Emergency or sudden hospitalization: In the event of emergency hospitalization in the network hospital, the claim formalities must be completed within 24 hours of actual hospitalization. The whole process is expedited once the pre-authorization form is completed on the insured side. TPA, in such a situation, also tries to process the claim request on the same day.

Cashless Health Insurance Inclusions and Exclusions


  • Pre and post-hospitalization expenses.
  • In patient hospitalization costs such as daily room rent, doctor fees, intensive care unit (ICU) charges and more.
  • Ambulance charges.
  • Annual health checks.
  • Day care.
  • AYUSH treatment.


  • Pre-existing illnesses.
  • Plastic surgery.
  • Self-inflicted injuries.
  • Dental and hearing care.
  • Illegal acts such as drugs and alcohol.


How to view list of cashless hospitals while using cashless claims?

You will obtain the list of hospitals in the network on the official websites of your insurer as well as your TPA. You can also find out which network hospitals are closest to your area.

Why should I consider buying a cashless health insurance policy?

What should I look for before buying a cashless health insurance policy?

Can I use cashless services only at network hospitals?

What is a network hospital?

Do I have to pay extra for cashless treatment?


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