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A health claim can be settled in one of two ways. Under a cashless settlement the insurer settles the admissible cost of treatment with the hospital directly, so the insured member does not have to fund the bill and claim it back. Under a reimbursement settlement the insured member pays the hospital and then claims the admissible amount back from the insurer.
Which of the two applies depends on where the treatment is taken. Cashless settlement is available only at a hospital that is part of the network for the policy concerned; treatment anywhere else is settled by reimbursement. Both routes are governed by the terms, conditions, limits and exclusions of the policy issued, and both require the claim to be admissible under that policy.
Kshema General Insurance Limited's own cashless and reimbursement settlement processes - including the network hospital list, the claim intimation channels and the administrator handling them - will be published on this page once the relevant health insurance product is made available. Until then, what follows is general information about how the two routes work, and is not a description of a facility currently offered by the Company.
| What happens | Cashless settlement | Reimbursement settlement |
|---|---|---|
| Where it applies | Treatment taken at a hospital in the network for the policy concerned. | Treatment taken at any other hospital, and any claim where cashless was not sought or was not approved. |
| Who pays the hospital | The Company settles the admissible amount with the hospital directly. | The insured member pays the hospital and then claims the admissible amount back from the Company. |
| What the member pays | Only the amounts the policy does not cover - any deductible or co-payment, non-medical items, and any sum above the limit available. | The whole bill at discharge. The admissible amount is paid to the member once the claim has been assessed. |
| Pre-authorisation | Required. The hospital raises the request and the Company confirms the amount it will pay before or during the admission. | Not applicable. The claim is assessed after the treatment, on the documents. |
| When to tell the Company | Before a planned admission, and within the period the policy allows in the case of an emergency admission. | Within the period the policy allows for intimating a claim, whether or not cashless was attempted. |
| Who submits the documents | The hospital, which sends the bills and the treatment record to the Company. | The insured member, who submits the claim form, the discharge summary, the original bills and payment receipts, and the investigation reports. |
| How the outcome is communicated | To the hospital and to the member, stating the amount approved and the amount left for the member to settle. | To the member, stating the amount admitted and the reason for any deduction. |
This table describes how cashless and reimbursement settlement work in general. The route available on a particular claim, the period for intimating it and the documents required are those set out in the policy issued, which prevails over this page.
To intimate a claim or to follow one up, please use the . The hospitals covered under a policy are published in our list of hospitals.
If you are not satisfied with the way a claim has been handled, our process sets out how to raise the matter and how it is escalated.
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