Types of Health Insurance Claims & Diff between Cashless vs Reimbursement Explained
When it comes to health insurance, you make a health insurance claim when you end up visiting a hospital due to an accident or illness. And when you make these claims you can either opt for a cashless claim or a reimbursement claim.
Essentially, you can get your treatment and later get your hospital bills reimbursed from your health insurer. Or, on the other hand, you can get an approval beforehand or at the time of admission (in case of an accident or emergency) and go for a cashless claim.
What is a Cashless Claim in Health Insurance?
A cashless claim is a type of health insurance claim where you can get treated at a network hospital without paying out of your own pocket. Instead, the costs are sent directly from the hospital and settled by the insurer.
So, you can head to one of your insurer’s network hospitals and show them your health e-card and ID proof. Just remember that you need to get your claim approved by your health insurer. This should be done at least 72-hours in advance if you’re going for a planned hospitalization or within 24-hours of being admitted in case of a medical emergency.
Then, you can get all your treatments done and then share the required claims forms with the third-party administrator or TPA (they are a mediator between the hospital and your health insurer). And that’s it. The insurer will take care of your claims.
What is a Reimbursement Claim in Health Insurance?
The second type of health insurance claims are reimbursement claims. In this type of claim, you can visit any hospital, not just those under your insurer’s cashless network. Here, you get your treatment done at the hospital, pay out of your pocket, and then apply for a reimbursement for the expenses with your insurer.
At the time of making the claim, you’ll need to submit all your hospital bills, prescriptions, and medical documents. These will need to be approved before your claim is processed, meaning that it can take slightly more time to get through.
Difference Between Cashless vs. Reimbursement Claims
Here’s a quick table to help you understand the key differences between the two main types of health insurance claims – cashless and reimbursement.
| Parameters | Cashless Claim | Reimbursement Claim |
| What is it? | In a cashless claim, you visit a network hospital and your health insurer will take care of the bills. | In a reimbursement claim, you pay your hospital bills after treatment. Then you must submit these bills and any other medical documents to your insurer to have your claim approved. |
| What is the claims process? | Choose a network hospital. Get the treatment approved by your insurer in advance. Share your health e-card and ID proof with the hospital authority and fill in the required forms. Share the forms with the Third-Party Administrator and insurer. Wait for the claims to be settled. | Get your treatment done and collect the relevant documents and bills. Once this is completed, fill in the required forms and share the documents with your insurer. Wait for the insurer to process the reimbursement. |
| How are claims settled? | The insurer will settle the claim directly with the hospital by making the payment on your behalf. You don’t need to pay any cash up front. | You need to pay for all the hospital expenses out of pocket first, and later the insurer will reimburse the expenses. |
| Do you need to get claims approved? | Yes. You need to get your claims approved by the insurer beforehand. This should be at least 72-hours before in case of planned hospitalization, and within 24-hours in case of a medical emergency. | No, you don’t need to get your claim approved beforehand. But it is a good idea to check with your insurer if your treatment will be covered or not. |
| How long will your claims take? | At the time of claim settlement, cashless claims are usually settled almost instantly. | Reimbursement claims are initiated after your treatment. Since it requires documents to be verified, it can take between 2 to 4 weeks. |
| What documents are required? | With a cashless claim, you just need to fill in the required form given by the TPA at the hospital. You don’t need to submit bills or other documents. | For reimbursement, you need to submit your health invoices, including medical bills, doctor’s prescriptions, and any other relevant information. |
| Is it applicable in all hospitals? | Cashless claims are only applicable with your insurer’s network hospitals. | Reimbursement claims can be done through any hospital. It doesn’t matter if it is part of a network hospital or not. |
FAQs about Types of Health Insurance Claims
What are the benefits of a cashless health insurance policy?
There are a number of benefits when it comes to having a cashless insurance.
- Fast Claims – When it comes to cashless claims, they are usually processed much faster.
- No Cash Needed – You don’t have to dip into your savings for medical expenses and then wait for reimbursement.
- No Paperwork – A cashless policy involves almost no formalities and paperwork.
- No Hassles – In a cashless claim, payments take place between the hospital and the insurance company, so everything will be taken care of.
What is a network hospital?
A network hospital is a hospital that has a tie-up with your insurer. Once it is part of your health insurer’s network, you will be able to get the option of cashless treatments at that hospital.
Do I have to pay anything from my pocket during a cashless claim as well?
This will depend on whether or not your health insurance has a co-payment clause. In this case, even with a cashless claim, you will have to pay the co-payment amount out of pocket. (For example, if co-payment is 10%, you will have to pay 10% at the time of discharge and the rest 90% will be cashless). But if your insurance doesn’t have a co-payment clause, you don’t need to pay anything from your pocket during cashless claims, as long as your hospital bill is less than your total sum insured available.
What all documents do you need to submit while making a cashless or reimbursement claim?
The documents you need will depend on the kind of claim you make. For Cashless Claims, you just need to fill in the required form given by the TPA at the hospital. On the other hand, for a Reimbursement Claim, you will need to submit your health invoices, including medical bills, doctor’s prescriptions, etc.