Cashless Health Insurance Claims Challenges

The health insurance policies have gained traction in the present scenario, as a modern consumer understands all its advantages. The insurers constantly modify the features and benefits of their policies to delight the consumers. Cashless health insurance is a type of policy that has also received a lot of limelight recently. It is a type of policy in which the individual need not pay the expenses related to hospitalization from his/her own pocket. The leading health insurance companies get associated with different hospitals as a part of this scheme. As a result, the expenses are paid directly by the insurer.

It has become quite a popular concept, as the individuals don’t have to worry about arranging the cash in case of an emergency. Some insurance companies extend this policy even for the hospitals located outside India. A lot of self-employed individuals prefer cashless insurance schemes due to lack of consistency in terms of income.

Types of Cashless Health Insurance in India

Cashless health insurance can be divided into two categories on the basis of individuals insured:

Cashless Insurance for Senior Citizens

It is a type of insurance for senior individuals that consists of hospitalization-related cover, along with ambulance charges. The cover associated pre-existing diseases may vary from policy to policy.

Cashless Family Health Insurance

It is a type of insurance in which an individual can get himself/herself covered for policy. Most of the insurers offer floater health insurance plans under which the whole family of the consumer can be covered.

It is also essential to understand two major concepts related to the handling and execution of cashless health insurance:

  • Preferred Provider Network (PPN):  In this concept, the insurers are associated with hospitals for offering cashless services to the insured individuals.
  • Third Party Administrator: In the third party administrator concept, there is a mediator that manages the settlement of claims between insurance service providers and insured individuals.

Major Challenges in Cashless Insurance

Though the cashless policies sound like hassle-free scheme, they may come with a lot of challenges.

  • Partial claim settlement: A very common challenge faced by policyholders is that only partial claim is provided by insurer as a part of cashless insurance. The individual has to pay the remaining amount from his/her pocket, which is later reimbursed.
  • Exclusion of treatments :Though most of the medical conditions and emergencies are covered under insurance plans, there are exclusions in most of the policies. These exclusions can be related to hereditary disorders, pre-existing illnesses, routine medical examination, dental procedures, etc.
  • Delay in the cashless facility: In some cases, the intermediaries (TPAs) require some time to process the claim and facilitate the treatment. The consumer, in these cases, not only has to face a lot of hassles but also has to bear the expenses from their pocket. Though, the company reimburses the expenditure later.
  • Unavailability of hospitals: Sometimes, the customers are not aware if a hospital has tied-up with an insurer for cashless facility or not. This issue can prove to be disastrous in case of emergencies.
  • Documents-related hassles: To avail the benefit of cashless treatment, the policyholder needs to submit a pre-authorization form to TPA. More often than not, policyholders fail to meet these requirements, especially during emergencies.

How to Avoid These Challenges

To get rid of these challenges, the policyholders need to have a systematic approach. The insured individual must go through the list of treatments that are not covered in a cashless facility. Comparing the exclusions of different insurers will make it easy to finalize the ideal one. One can take the support of portals that allow comparison of different health insurance policies.

Being aware of the PPN hospitals that come under the cashless facility of a specific insurer is also a sane idea to avoid surprises at later stages. The staff of some hospital may not be very efficient and active when it comes to executing the policy-related process. Therefore, choose only the reputable hospitals to avoid any hassle.

Do not skip the procedure related to pre-authorization form, which is to be submitted with TPA. For emergency cases, the form is supposed to be submitted within 24 hours of hospitalization. For planned treatments, an individual must try to submit the form 4 to 5 days prior to hospitalization. The policyholders must also submit all the hospital bills to ensure efficient settlement.

Sometimes, the agents keep the opacity related to the features of policy. Go through the website or contact a customer support representative to get clarity.


If done in a strategic manner, the cashless health insurance in India can, indeed, prove to be beneficial. A lot of companies are now delighting policyholders through exciting benefits like no paperwork, easy renewal, tax benefits, etc. Go through these benefits and cashless-related features to the plan that can help you remain stress-free.

Harjot Singh Narula

Harjot Narula is founder and CEO of, an IRDAI approved insurance web aggregator focussed on selling online insurance for companies. Harjot has more than a decade of experience in software development and has also spent 5 years in US working for the mortgage and risk management industry.

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