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There are two types of claims in health insurance: cashless claims and reimbursement claims. They differ in how payments are handled during the medical treatment process, and understanding how they work ensures you get financial assistance quickly during emergencies.
At Reliance General Insurance, we offer a streamlined process for both health insurance claims processes to help you easily access their benefits. Here is a quick guide to drive you through the medical claim types.
The two types of claims in health insurance are cashless claims and reimbursement claims.
In a cashless claim, we directly settle the hospital bills, while in a reimbursement claim, you pay the expenses upfront and later submit the receipts to us for reimbursement.
While cashless claims provide a straightforward and hassle-free experience, reimbursement claims offer greater flexibility in managing expenses.
You can decide between these types of medical insurance claims based on your individual circumstances and financial requirements.
However, the type of health insurance claim can be specific to a medical expense. For instance, generally, pre-and post-hospitalisation expenses can be settled only as a reimbursement claim.
The steps required to access the benefits through these types of claims in healthcare are different.
Let us explore cashless vs reimbursement in health insurance and understand the respective health insurance claim process.
A cashless claim in health insurance refers to a type of health insurance claim process that lets you receive treatment at a hospital while we settle the bills directly with them.
Cashless claims were previously applicable only to network hospitals. However, with the recent GIC announcement, cashless claim facilities are available at all hospitals in India.
However, it’s still worth noting that it’s easier and quicker to file and process cashless claims at our network hospitals versus filing a cashless claim at a non-network hospital since we have preset processes in place to ensure quick claims processing.
Claim Intimation - As the first step, you need to inform us about the cashless claim and the incident. You can contact us for the health insurance cashless facility in the following ways:
Paid helpline number - +91 22 48903009
Email address - rcarehealth@relianceada.com
Mobile App - Reliance Self-i App
Receive the Treatment - Upon approval, receive the treatment necessary for your medical condition.
Claim Settlement - At the end of the treatment, verify and sign the bills at the hospital for the health insurance claim process. We will examine and settle the applicable expenses directly at the hospital.
Differentiating Factors
Cashless Planned Treatment
Cashless Emergency Treatment Claim
Claim Intimation
At least 48 hours before the hospitalisation
Within 24 hours of hospitalisation
Pre-Authorisation
● Coordinate with the hospital prior to the treatment process and get the medical records and pre-authorisation form.
● Fill out the necessary details and submit the documents for approval.
● Present the pre-authorisation approval at the time of visiting the hospital.
● Get the pre-authorisation form from the TPA after getting admitted.
● Fill out the necessary details and submit it for approval.
A reimbursement claim in health insurance allows you to pay for the medical treatment out of your pocket and, later, submit the receipts for reimbursement.
Claim Intimation - Inform us about the need for medical claim reimbursement by contacting us in any of the following ways:
Visit a Hospital and Receive the Treatment - Visit any authorised hospital and receive the treatment for your medical condition.
Pay the Applicable Expenses - Upon completing the treatment process, pay the applicable expenses.
Submit Documents - Submit the scanned documents, including the medical records, bills and receipts, to us within 7 days for mediclaim reimbursement.
Claim Settlement - We will verify your reimbursement medical claim and compensate you for the applicable expenses.
Differentiating Factors for Cashless and Reimbursement Claims
Cashless Claim in Health Insurance
Reimbursement Claim in Health Insurance
Purpose
To provide effortless health insurance claim experience by settling the bills directly with the hospital.
To reimburse the bills later after you have made the payment, offering greater flexibility.
Health Insurance Claim Process
Claim intimation, followed by pre-authorisation and claim settlement.
Claim intimation, followed by payment of medical expenses out of your pocket and claim settlement.
Claim settlement
We will directly settle the bills at the hospital.
You will pay the expenses upfront, and we will reimburse you later after you submit the bills and receipts.
Hospital
Network or non-network hospital. The process is simpler in a network hospital.
Any authorised hospital
Processing time
Quicker, as it is settled at the end of your treatment and discharge.
Takes slightly longer as it is settled after you submit the bills and receipts.
Documentation
Minimal documentation, especially in network hospitals
More documentation with complete details being gathered at your end
Benefits
Simpler, less time-consuming and minimal documentation.
Greater flexibility - You can receive the treatment primarily and go through the main claim process later after discharge.
Pre-Hospitalisation Claim
Post-Hospitalisation Claim
Meaning
Coverage for medical expenses incurred before hospitalisation
Coverage for medical expenses incurred after discharge
Coverage Duration
Medical expenses incurred 90 days immediately preceding hospitalisation for the medical treatment.
Medical expenses incurred 180 days immediately after the discharge.
Condition
The expenses should have been incurred for the same illness or medical condition for which you are being hospitalised.
Coverage
The coverage is applicable to inpatient care, specialised treatment procedures, domiciliary hospitalisation, daycare procedures and AYUSH treatment
Pre-and Post-Hospitalisation Claim Process
Generally, only reimbursement claims are applicable. However, it is subject to the type of health insurance policy and its terms and conditions.
A daycare procedure refers to medical treatments or non-invasive/minor surgeries that require less than 24 hours of hospitalisation. Out-patient treatments are not covered under day care health insurance claims for short-term treatments.
Claim Types in Healthcare - Daycare Procedure Claims
Common Procedures
● Surgical procedures under general or local anaesthesia
● Specialised treatments, such as chemotherapy, radiotherapy or haemodialysis
● Any other treatment that requires less than 24 hours of hospitalisation
Claims Applicable
Both cashless and reimbursement claims are applicable.
The required documents for a health insurance claim process may vary slightly depending on the type of claim you are filing. Here is a list of common documents required for types of medical insurance claims, along with additional documents specific to each type of claim.
Medical Insurance Claim Documents
Common Documents
● Claim form
● All medical documents, including investigation reports, diagnostic test reports, treatment records, prescriptions, etc.
● Discharge Summary
● Medical Practitioner’s Certificate
● Stickers and invoice of implants used in surgery
● Copy of FIR (First Information Report) or MLC (Medico Legal Case), in case of accident
● Copy of settlement letter from other insurance providers, if applicable
● Legal heir certificate, in case of death
Health Insurance Cashless Claims
● Pre-authorisation form
Health Insurance Reimbursement Claims
● Original bills
● Payment receipts
● Original Cancelled Cheque in CTS 2010 format
Pre-and Post-Hospitalisation Claims
● Pre-and post-investigation reports
● Follow-up records
Please Note: Additional documents may be requested based on individual circumstances.
If you own multiple health insurance policies, you need to file one claim at a time to cover your medical expenses. Upon getting your health insurance claim settled with one insurer, you can contact the second insurer for the remaining amount.
While contacting the second insurer, you need to provide a copy of the health insurance claim settlement document received from the first insurer. The second insurer will examine your claim and compensate for the remaining expenses.
When you have very little money in savings, a health insurance claim rejection can cause a lot of distress. Therefore, understanding claim rejections and their common causes can help you avoid them.
Some of the common health insurance claim rejection reasons are as follows:
Third-Party Administrators (TPAs) serve as intermediaries in the health insurance claim process, bridging the gap between policyholders, insurers and hospitals. Their primary role is to facilitate a streamlined health insurance claim process.
TPAs in health insurance are responsible for the following roles:
The better option depends on your individual circumstances and financial situation. Cashless claims enable you to receive treatment without upfront payment since we directly settle the bill with the hospital. On the other hand, a reimbursement claim requires you to pay first and then later claim the expenses later.
You can consider your specific healthcare requirements and financial situation to decide on a suitable type of claim in health insurance. For instance, in the event of an emergency, opting for a cashless claim can be beneficial. On the other hand, if you are in a better financial situation, you may opt for the reimbursement claim.
A health card is a document that serves as proof of your health insurance coverage. It contains your personal information and health insurance policy details. This health card needs to be presented at the network or non-network hospital when accessing cashless claim facilities.
At Reliance General Insurance, we process reimbursement claims within 15 days from the date we receive the last required document.
You need to notify us about the cashless claim for a planned treatment at least 48 days prior to the hospitalisation.
You can reach out to us through any of the following ways to notify us of a claim or to clarify any doubts regarding your claim.
Claim settlement ratio refers to the number of health insurance claims settled by an insurer against the number of claims registered by their policyholders – in a year.
On the other hand, the incurred claim ratio compares the total amount paid in claims to the total premiums collected.
A high claim settlement ratio means a larger proportion of the claims registered by the policyholders have been successfully processed and paid for by the insurer.
If the incurred claim ratio is higher, the insurer might revise their premium and policy terms and conditions to maintain their financial stability.
There is generally no limit on the number of claims you can file during the policy period. However, you cannot raise a claim once the sum insured has been exhausted.
If your health insurance policy includes benefits like Double Cover, Restore Benefit or Unlimited Restore Benefit, the number of claims allowed will be based on the extended sum insured.
Yes, you can raise a health insurance claim process health insurance claim every policy year.
You can claim up to the total amount of your sum insured.
Disclaimer: *T&C Apply. For more details on risk factors, terms conditions, brochure, and exclusions, please read the policy wording and CIS carefully before concluding a sale.
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