Cashless vs reimbursement claims: how does each work?

In a cashless claim, the insurer pays a network hospital directly for covered treatment, up to the amount it pre-authorises; you pay only for items it does not cover. In a reimbursement claim, you pay the hospital and then claim the money back with your documents. Cashless needs a network hospital and pre-authorisation; reimbursement is the route at other hospitals, or when cashless is refused.

How a cashless claim works

1. 1

   Go to a network hospital

   A network provider is a hospital enlisted by the insurer or its TPA to treat insured people on a cashless basis. Insurers must list on their websites the hospitals with which they have a cashless tie-up.^{[1, 2]}

2. 2

   The hospital asks for pre-authorisation

   The hospital sends a cashless request with your medical details. The insurer must decide immediately, and in any case within one hour of receiving it.^[2]

3. 3

   Discharge

   The insurer must give final authorisation within three hours of the hospital's discharge request, and you must not be made to wait to be discharged. Any extra amount the hospital charges because of a delay beyond three hours is borne by the insurer.^[2]

4. 4

   You pay only what is not covered

   In one insurer's wording, you verify and sign the discharge papers and pay for non-medical and inadmissible expenses; the insurer pays the hospital directly for covered treatment, to the extent pre-authorisation was approved.^[1]

How a reimbursement claim works

1. 1

   Tell the insurer

   Give notice within the time your policy sets. One insurer's wording asks for notice within 24 hours of an emergency admission and at least 48 hours before a planned one.^[1]

2. 2

   Pay and keep the papers

   Keep the bills, payment receipts, discharge summary, reports and prescriptions. Once a claim is intimated, the insurer and TPA must collect the required documents from the hospital, but your own copies are your proof.^[2]

3. 3

   Submit the claim

   Send the claim form and documents within the policy's time limit — within thirty days of discharge in one insurer's wording.^[1]

4. 4

   Settlement

   A claim other than cashless must be settled within fifteen days of submission. If it is not settled within the timelines, IRDAI's circular gives interest at the bank rate plus 2% from the date the claim was intimated; one insurer's wording counts it from the last necessary document instead, so check yours.^{[3, 1]}

The differences that matter

A refused cashless request is not a rejected claim. Insurers must make clear that treatment outside their cashless network is claimed by reimbursement, and one insurer's wording says that if cashless access is denied you can take treatment on your doctor's advice and claim reimbursement. IRDAI has also asked insurers to strive for 100% cashless settlement — a target, not a promise that every admission will be cashless.^{[2, 1]}

Cashless refused at the hospital covers what to do at the desk; filing a reimbursement claim covers the paperwork.

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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