Page 235 - Ebook health insurance IC27

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The settlement is done directly by the insurance company to the hospital/nursing
via the TPA, which undertakes to handle the claims on behalf of the insurers.
However, for getting admission and availing of the cashless facility, prior approval
needs to be taken by the patient.

The hospitals which have an agreement with the TPA are referred to as' Network
Hospitals'. Cashless facility is provided for treatment at these hospitals only. For
other Non-Network Hospitals, the claims are paid as reimbursements i.e the
customer has to pay to the hospitals first & then claim reimbursement to the TPA.

Q3. What is cashless- claims, discuss its types.
Ans. Cashless claims can be of two types
(i) Planned - where the insured is aware of the hospitalization at least 2/3 days in

advance.
(ii) Emergency - where the insured or his family meets with sudden accident or suffers

from a bout of illness that requires immediate hospitalization.

The procedure for making a claim varies from company to company, product to
product , or on policy terms. However, some general points have to be kept in
mind for speedy settlement and lesser rejection of claims.

The claim settlement paid by the Insurance Company comprises only of the
expenses admissible and actually incurred. On the other hand, in case of benefit
policies like hospital daily cash and critical illness policies, the insured is paid the
pre-specified amount regardless of the actual expenses incurred.

Claims that are not admissible, partly or fully, as per the policy conditions, can be
repudiated or rejected by the insurers. It is important to know that partial reductions

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