Can I get cashless treatment at a hospital that isn't in my insurer's network?

Generally not as of right: cashless works through hospitals in your insurer's or TPA's network, and IRDAI requires insurers to state on their websites that treatment elsewhere has to be claimed by reimbursement. IRDAI has asked insurers to work towards wider cashless access, but that is an aim, not something you can insist on at the admission desk. Ask your insurer or TPA in writing before a planned admission, and if you use a non-network hospital, plan for a reimbursement claim.

This is a question to ask before admission if you can. The answer decides whether the hospital will deal with your insurer directly, or whether you pay the bill and claim it back afterwards.

Network and non-network, as one wording defines them

• Network provider: A hospital enlisted by the insurer or its TPA, or both jointly, to treat insured people through a cashless facility.^[1]
• Non-network provider: Any hospital that is not part of the network.^[1]
• How cashless works: Treatment is taken at a network provider and is subject to pre-authorisation by the insurer or its TPA.^[1]

What insurers must do, and what is only an aim

IRDAI's health master circular requires insurers to display on their websites the hospitals tied up with them for cashless settlement, and to state specifically that if you are treated elsewhere, the claim has to be filed for reimbursement.^[2]

The same circular tells insurers to strive for 100% cashless settlement, and says insurers along with the insurance councils may endeavour to set up common empanelment of hospitals so that cashless can be used anywhere. These are aims. They do not give you a right to cashless at a particular non-network hospital.^[2]

Before a planned admission

1. 1

   Check the network list

   Look up the hospital on your insurer's or TPA's website list of cashless hospitals.^[2]

2. 2

   If it is not listed, ask in writing

   Email the insurer or TPA with the hospital's name and the planned date, and ask whether cashless will be available. Keep the reply.

3. 3

   Give notice in time

   Your policy sets a notice period for planned admissions. One insurer's product, for example, asks for notice at least 48 hours before a planned admission.^[1]

4. 4

   Check the hospital is not excluded

   One insurer's wording excludes treatment at hospitals it has specifically excluded and disclosed, paying only up to stabilisation in a life-threatening situation or after an accident.^[1]

If you are already at a non-network hospital

Pay the bill and claim reimbursement, keeping the full set of hospital papers. Once you intimate the claim, the insurer and TPA are to collect the required documents from the hospital, and a reimbursement claim must be settled within 15 days of submission. For the steps, see filing a reimbursement claim.^{[2, 3]}

ClaimAssure is an independent private platform. It is not an insurer, IRDAI, Bima Bharosa or the Insurance Ombudsman, it never files anything on your behalf, and it cannot promise any outcome. What it does is read your documents and show you what they say.

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