Insurance & Claims
Cashless Claim
A cashless claim lets an insured person get hospital treatment at a network hospital while the insurer settles the approved bill directly.
What is a cashless claim?
A cashless claim is a way of using health insurance where the insurer (or its third-party administrator, the TPA) pays the hospital directly for approved treatment. The patient does not pay the covered amount upfront and claim it back later.
Cashless treatment is available only at network hospitals – hospitals that have an agreement with the insurer or TPA. The patient still pays for anything the policy does not cover, such as non-medical items, co-pays or amounts above limits.
How the cashless process works
- Check the network. Confirm the hospital is in the insurer's or TPA's network.
- Pre-authorisation. The hospital's insurance desk sends a request with the doctor's diagnosis and estimated cost. For planned treatment, this is done in advance; for emergencies, soon after admission.
- Approval. The insurer or TPA reviews the request and approves an amount, asks for more information, or declines cashless (in which case a reimbursement claim may still be possible).
- Treatment. If the stay or cost changes, the hospital requests an enhancement.
- Discharge. The hospital sends the final bill; the insurer approves the final amount and the patient pays only non-covered items.
Why it matters for employers
A hospital admission is stressful. Cashless settlement removes the burden of arranging large sums at short notice. Delays at admission or discharge are among the most common employee complaints about health benefits, so how claims are supported directly affects how employees feel about the benefit.
Employers and their brokers can help by:
- Sharing e-cards and simple "how to go cashless" guides
- Keeping network hospital lists easy to search
- Providing a support contact who can follow up on pending approvals
Example
An employee's wife is admitted for a planned delivery at a network hospital. Two weeks before, the hospital submits a pre-authorisation request and it is approved. At discharge, the hospital sends the final bill, the insurer approves it within the maternity limit, and the family pays only for a few non-medical items and the amount above the limit.
Key takeaways
- A cashless claim means the insurer pays the network hospital directly for approved treatment.
- Pre-authorisation is required; planned admissions should be intimated in advance.
- Patients still pay non-covered items, co-pays and amounts above sub-limits.
- Learn about our employee health benefits experience and support for insurers and TPAs.