A key advantage of health insurance is the benefit of cashless claim settlement when a policyholder is admitted to a hospital for treatment — whether it is planned or emergency-driven. Cashless treatment is generally allowed by insurers when admitted in their empanelled or network hospitals.

But late this January, the General Insurance Council rolled out a new initiative called ‘cashless anywhere’ that allowed insurers to settle claims even when treatment is taken in non-network hospitals.

When there is a large list of network hospitals provided by any insurer, will anyone prefer a non-network hospital? Consider a few situations. What if there is a medical emergency that you or a family member face when traveling outside your home/city of residence?

Or, what if there is extreme lack of time, flooding, heavy rains, massive traffic or road blockage along the route to a network hospital, necessitating an immediate shifting to some accessible hospital outside your insurer’s network during an emergency? There could be several other types of emergencies, too.

But do note that the new cashless anywhere facility is available even in the case of planned treatments, although it would be reasonable to assume that most policyholders would choose a specific network hospital well in advance in such cases.

So, how does the cashless anywhere initiative work for policyholders — what factors change and what remains as before?

Read on to take an informed call on how the process can be made smooth in the case of cashless treatment at non-network hospitals.

What it takes to go cashless

A few insurers were offering the cashless facility in non-network hospitals even before the new norms came into effect last month. Now, many insurers including ICICI Lombard, HDFC Ergo, National Insurance, United India Insurance, Future Generali, Reliance General and Bajaj Allianz have come out with guidelines for availing cashless settlement at non-network hospitals.

Intimation on the planned treatment at a network hospital must be given to the health insurer or its TPA (third party administrator) 48-72 hours before the hospitalization depending on the insurance company. This can be done in writing or email or other insurance-specified online and offline modes.

In the case of emergency, intimacy must be done within 24-48 hours of admission to the hospital.

The non-network hospital must have at least 15 beds for you to take cashless treatment. Also, the non-network hospital must satisfy the terms and conditions as well as definitions of running a hospital as per the health insurance policy.

All the identity cards, policy documents, medical reports, prescriptions and bills are expected to be in the prescribed format.

Many insurers also ask for a letter of consent from the non-network hospital before permitting cashless settlement. This consent letter allows the insurer to verify if the hospitalization bills are genuine, standard acceptable admission processes are in place, the line of medical treatment is necessary, the hospital adheres to legal and statutory requirements and so on.

Others ask the non-network hospital to accept a memorandum of understanding (MoU) in physical format before agreeing to cashless treatment.

Conditions apply

Most other aspects of cashless settlement remain unchanged even when you take the cashless anywhere facility.

So, the clauses relating to standard waiting period, co-pay clauses, excluded benefits, pre-existing diseases and the like will not change.

Also, if there are certain upper ceilings on the settlement amount relating to ailments, especially day care procedures such as cataract removal and so on, the stated policy amount for such operations would remain unchanged.

Settlement of claims would also usually exclude consumables (cotton, face masks, surgical gloves, nebulisation kits, etc), administrative and possible charges, unless allowed in the health insurance policy or via a rider taken to include these.

The insurance clause on room rent ceiling (if any) would continue to apply and all other costs are pro-rated based on the room rent. Any excess charges would have to be borne out of the policyholder’s own pocket.

One extremely important point to note is that if a non-network hospital is on the excluded list or is blacklisted by your insurer, your claim will not be entertained. It is thus important for you to keep a tab over the list of excluded hospitals list from your insurer’s website so that you avoid them even if there is an emergency.

Overall, the idea to bring network and non-network hospitals at par for cashless treatment is a welcome move, although it would be safe to take the network hospital route for all planned procedures.

Health insurance: What The New ‘Cashless Anywhere’ Initiative Entails

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