When Cashless claims can be denied by the Hospitals

The Insurance Regulatory and Development Authority of India have observed that recently many hospitals are denying the cashless treatment facility to the policyholders. According to section 31 (d) of IRDAI, insurance companies shall have an agreement with private and public healthcare institutions. The list of network hospitals shall be published along with the policy document. Policy terms shall clearly specify that IRDAI shall direct Insurance Companies to deliver smooth cashless treatment to policyholders.

Know Your Claims:

On the basis of network and non-network hospitals claims can be divided as reimbursement and cashless. In cashless claims insured shall not pay the bills. However, in reimbursement scenarios, policyholders shall pay in cash at first instance and later can be recovered by reimbursement from the hospital. In Agreement there shall always be a list of empanelled and non empanelled hospitals.

When Cashless Claims Can Be Denied? 

Even a cashless facility can be denied in a network hospital to a policyholder , if the information sent by the hospital is insufficient or in case the ailment is not covered under the policy or the request of pre-authorization is not sent in time. 

However, if the cash facility is denied one can subsequently on discharge from hospital submit a claim for reimbursement.

Hospitalisation can either be planned or a medical emergency. Under any of these circumstances the insurer shall be intimated immediately upon hospitalisation by submitting a pre authorization form.

Direction of IRDAI:

The Insurance Regulatory and Development Authority of India issued a circular which aimed at discouraging healthcare providers from taking large amounts of money as deposits from patients and denying them cashless claims.

The circular says, “It is clarified that the policyholders are entitled to the cashless facility at all such network providers (hospitals) with whom the insurance company/TPA (third party administrator) has entered into an agreement in accordance with the norms of service level agreement (SLA).”

Redressal:

Policyholders can file a complaint by writing to the grievance redressal officer of the insurer details of which will be mentioned on the respective website of the insurer.

Insurers have been asked to put in place exclusive grievance redressal mechanisms and policies to address complaints relating to the denial of cashless claims.

Therefore, it is clear that policyholders can avail cashless facility in all network provider’s or hospitals that are registered with the insurer as per terms of Service Level Agreement.

In the event policyholder’s interests are affected adversely because of conduct of health care advisers, IRDAI said that it shall be immediately notified to the appropriate government or agency.

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