Cashless health insurance claims make life easy as one does not need to pay for medical expenses from one’s pocket. Still, with the best coverage, there is the possibility of claim denials. In this blog, we will discuss some of the common reasons your cashless claim may get rejected and how to avoid such pitfalls.

Overview of Cashless Health Insurance Policies

Cashless health insurance policies are designed to extend financial protection in case of medical emergencies by allowing direct settlement of medical bills with network hospitals. This saves the policyholder from making any upfront payments, thus making the entire process smooth and hassle-free.

The general key features include pre-hospitalisation expenses up to 60 days prior to admission and post-hospitalisation expenses up to 90 days post-discharge. These policies typically cover in-patient costs, ambulance services, daycare treatments, and regular health check-ups. A high claim settlement ratio signifies efficiency and reliability in the speedy settlement of claims by an insurer. Many insurers also have health administration teams working at their back-end to ensure that claims get settled quickly with minimum complication.

8 Reasons Why Your Cashless Health Insurance Claims Get Rejected

Treatment Availed at a Non-Network Hospital

Cashless claims are usually available at hospitals that come within the network of the insurer. For treatment sought at a hospital outside the network, you may have to pay for the same and subsequently file for reimbursement. The good news is that most insurers maintain a long list of network hospitals, so finding one isn’t a task.

Lack of Pre-authorization

It is very important to secure your insurer’s prior approval for any scheduled treatments. In this case, the insurance company approves the treatment and cost in advance of when the treatment actually starts. Lack of this may lead to claim rejection. Though emergencies may sometimes circumvent this initially, it is very important to notify them as soon as one can.

Policy Exclusions

All health insurance policies have certain exclusions, which refer to those conditions or modes of treatment that are not covered under the policy. Some of the common exclusions include cosmetic procedures, alternative therapies, or even pre-existing conditions if one is within the waiting period. It is important that you go through your policy in great detail so as to know what is covered and not covered.

Incomplete or Incorrect Documentation

Documentation plays an important role in claims processing, and proper and full documentation is always required for a successful claim. It generally consists of a cashless claim form, original hospital bills, discharge summary, medical reports, and doctor’s consultation letters. Insurers usually provide detailed guidelines about the required documentation, whether the claims are initiated online or offline.

Incongruities in Provided Information

Any differences in the information at the time of purchasing the policy and at the time of claim are liable to be rejected. Ensure that the patient’s case history, treatment records, and personal information provided are correct and consistent.

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Delay in Notification to the Insurer

Timely notification to the insurer is, thus very important even in emergencies. Most insurers have allowed a specific timeframe after hospitalization for notification. Check your policy for details. Delays in notification could complicate the claims process and maybe denied.

Claim Amount Exceeding the Sum Insured

If the treatment costs exceed the sum insured of your policy, then you will have to pay the excess amount. It is, therefore essential to select a policy with an adequate sum insured to meet prospective medical expenses.

Failure to Disclose Pre-Existing Diseases

Failure to declare or incorrect declaration of the pre-existing condition when you purchased your policy may result in denial. The insurance company bases policy coverage and policy terms on good and adequate disclosure of health. Failure to provide correct information will be one of the important reasons for denied claims.

Conclusion

While cashless health insurance can ease the burden considerably in case of medical emergencies, it is imperative to understand some of the common reasons for claim denials. A well-structured cashless health insurance policy provides comprehensive coverage and a trustworthy claim settlement mechanism. However, if one knows where the potential pitfalls are and can take remedial measures in time regarding understanding one’s policy, accurate documentation, and timely communication, this will go a long way in securing maximum benefits from your cashless health insurance and help you avoid undesirable claim denials.