One of the features that health insurance companies highlight while selling a policy is the cashless scheme. Under the scheme, in case of hospitalisation, the customer does not have to spend a single penny from his or her pocket (within the insurance cover), since the hospital would recover the amount from the insurance company directly. But before you sign up for a policy, check if the hospital that you want to go to, or is convenient for you in case of a medical emergency, is part of the hospital's cashless network. A few years ago, public sector health insurance companies had completely stopped cashless schemes citing over-billing by hospitals in case of such companies. While the issue has been resolved to some extent, and PSU insurers have again started offering cashless schemes, the list of preferred hospitals has come down drastically. And as a customer there is not much you can do.
The advantage of a cashless scheme is that hospital charges typically tend to be lower than in case where the customer has to claim reimbursement, says Arvind Laddha, Vantage Insurance Brokers & Risk Advisors. According to Deepak Yohanan, CEO, myinsuranceclub.com, the list of hospitals is open to change any time. "It is an agreement between the insurance company and the hospital. If at any time the insurance company wants to take a particular hospital out of its list, it can. Customers can't do anything about it,'' he says.
What you can do before buying a policy is to check if the hospital that you prefer to go is part of the company's preferred list. But it might also happen that the particular hospital was part of the list when you purchased the policy but the tie-up ended by the time you needed treatment.
"There is no way customers can be sure that the cashless facility with the hospital will be available when they actually need to use it,'' Yohanan says. In case of group policies, customers don't even have this option. In fact, in most cases, they don't even know the details of the policy, such as the cover amount or the list of preferred hospitals and so on, he adds.
So, if you want to get treated at a high-end hospital, it is possible that the hospital may not be part of the network offered by your company. If so, you will have to pay from your own pocket and then claim the money from the company. That comes with its own set of problems like excessive queries by the insurance company, delays in paying the claim and so on.
Another issue could be when the doctor treating you practises at a particular hospital but that is not part of the network offered by your insurer, says Laddha. So, customers should check the list of network hospitals on the company's website. If the company has a Third Party Administrator (TPA) for claim processing, then you can ask the TPA for the list of hospitals. According to an official from a PSU insurer, there is a Preferred Provider Network (PPN) for retail customers and a list of network hospitals for corporate customers. In Mumbai, for instance, Breach Candy hospital is not part of the PPN but for some corporate customers it has been included in the network. "Although the number of hospitals in the PPN list had fallen for some time, it is slowing increasing," says Laddha.