What are Cashless Insurance Claims? What are the Reasons for the Hospitals to Deny Them?

People buy insurance and pay the premium every year with the hope that if a day comes when they need a treatment at a hospital, the insurer will bear the expenses on their behalf. However, that’s not always the case as sometimes a hospital may reject their claim.

But before we get to “why hospitals reject insurance claims”, let’s understand the two types of insurance claims first:

• Reimbursement claim: In this, you pay the hospital bills first and then the insurer reimburses the same for you later after you submit the receipts and other necessary documents.
• Cashless claim: This one is more popular and convenient as in this the treatments are “cashless”. So, you don’t have to pay the bills at all as the insurer takes care of these at the time of treatment itself.

Image Source

Since the insurance industry has become massive today, a number of healthcare groups as well as independent hospitals have joined hands with different insurance companies and become a part of their “network”. So, if you go to one of these hospitals for treatment, you can easily avail the “cashless” service. However, if the hospital you go to isn’t connected to your insurer’s network, then it’s possible that you can only avail a reimbursement claim.

What are the reasons for claim rejections?

For a hospital to approve an insurance claim, a standard procedure is followed. And if any anomaly is encountered in the middle, your claim could be rejected. This is possible even when you are raising an insurance claim with a network hospital.

Some of the common reasons for claim rejections include insufficient information provided to the hospital, or when the treatment in question is not covered by the insurance policy, etc. However, even if the claim is rejected, the policyholder can pay the bills on their own and approach the insurer later to get reimbursement.

To receive the reimbursement, you must have the following documents:

• Duly-filled claim form as well as the discharge summary
• All receipts of medical supplies, medicines, treatments, etc.
• Doctor’s consultation reports
• Investigation reports, in case FIR was filed