In a medical reimbursement, the policyholder pays the hospital bill and the amount is reimbursed by the cashless claim. In the case of a cashless claim, the policyholder is not expected to pay the hospital bills as the insurer reimburses the same directly to the hospital.
Well, that is how it works in theory. Not completely true in practice.
ANUJ JINDAL, co-founder of Sureclaim, explains.
Most policyholders assume that they are not liable to pay anything against a medical treatment if they are pre-authorized for cashless treatment. That’s not always the case. The insurance company can make a few deductions and for valid reasons.
If, as a policyholder, you have not read the terms and conditions carefully, a deduction will surely come as a disappointment.
Why does this happen? Why must the insured pay some fraction of the medical expenses at the time of discharge? Here’s why.
Exclusions
Most insurance policies do not cover every medical expense. Hence, the deductions due to non-admissible items or services when claiming medical insurance. For example, items used during the treatment such as gloves, hand sanitizers, etc. are not covered under the policy. Similarly, services such as admission fee, registration charge, medical record fee, insurance processing fee, etc. are also not non-admissible.
Co-pay
Co-pay is a policy factor according to which the policyholder is liable to pay a certain percentage of the total claim amount. Co-pay is applied on the dependents of the insured such as spouse, children and parents. Moreover, co-pay is also applied to every claim a senior citizen policyholder makes.
Room rent limit
You may not know it but room rents are capped. This means that an upper-limit is applied on the room rent. And if during hospitalization the policyholder chooses a room whose rent exceeds this upper-limit, a proportionate charge would be applied to all the treatment-related services.
For example, Anil is eligible for a semi-private room with rent up to Rs 4,000. Now if he chooses to stay in a deluxe room with rent Rs 8,000, he will end up bearing 50% of the total cost because of the proportionate deduction in the final claim settlement.
Neither will the insurance company cover the increase in the bill due to the room selection.
(For the same service in a hospital, patients are charged differently depending on whether they are in a general ward, semi-private room, private room or deluxe. The cheapest rates will apply to the general ward and the deluxe, the most expensive. So on all costs, which are over and above the rate applicable, the patient will have to pay for.)
Sub-limit on treatments
It is a very common assumption that if your total treatment cost is less than the sum insured, it will be covered. In reality, almost every treatment has a limit applied to it. And if the treatment cost exceeds the limit, you will have to pay the difference.
To understand this better, let’s suppose that Anita is insured under a policy for Rs 3 lakhs. According to the terms and conditions, normal delivery charges up to 30,000 and C-section delivery charges up to 50,000will be covered. So, if her maternity expenses exceed these specific amounts in either of the cases, she will have to pay the difference out of her pocket. This, despite being insured for up to Rs 3 lakhs.
Always remember....
Whether it is a cashless claim or a reimbursement claim, it is very important to know the benefits that you are entitled to. It is important that you know what your policy covers.