6 Reasons Why Your Cashless Health Claims Can Get Denied

By Okbima 13 May 2023
6 Reasons Why Your Cashless Health Claims Can Get Denied

The primary purpose of purchasing insurance is to make cashless health claims while hospitalized. Insured parties feel taken advantage of by the insurer if they are not provided with this benefit. Let's look at what the insured may do to prevent having their claim denied. 

The patient must enquire about the approval status at the TPA desk while hospitalized. Furthermore, they need to determine whether the hospital has addressed any questions regarding the case that need to be addressed. It can be guaranteed that all questions are addressed if the person keeps constant contact with their TPA department and the consulting physician.

A request for authorization of a cashless claim may be rejected for several reasons, such as the condition or illness for which hospitalization is necessary is not covered by the policy or the insured may not have enough remaining sum insured to pay the claim. The customer's desire to go cashless is thus rejected, and they cannot receive a reimbursement.

What Does Cashless Health Insurance Mean?

A cashless insurance policy is one in which the insurance provider and the network facility immediately pay for all hospital expenses. The owner of the insurance coverage is not required to pay any money.

It's quick and straightforward to purchase cashless insurance. The insurance company's network hospitals must be used for the policyholder's medical care. These network hospitals can offer cashless care via a partnership with the insurance provider. To confirm the policyholder's claims, officials of the insurance provider coordinate billing and other procedures. 

In other words, once the insurance company personnel have verified the claim, the policyholder becomes eligible for cashless health claims and treatments. The hospital receives authorization to treat the patient.

What Is Hospitalization Without Payment In Cash?

In a cashless hospitalization, the insured person is admitted for treatment, with the insurance provider covering all associated costs. Without the consumer's involvement, the insurance company would pay the hospital's bill directly. To do this, the insurance companies negotiate bundles with the clinics and set a price for a certain kind of therapy. The ideal way to pay claims under a health insurance policy is through cashless hospitalization and cashless health claims since people's ability to save money for hospitalization is seriously threatened by growing hospitalization expenses, which also severely threaten people's health.

What Type Of Cashless Hospitalization Is Excluded From My Health Insurance Plan?

Most cashless health claims are denied because of non-disclosure, which the business now recognizes in medical care and requires proof of prior medical care. Moreover, non-network hospitals refuse cashless payments. Therefore, in an emergency, you should always identify the network hospital closest to your house. Both the website and the policy bundle include the most recent version of the list.

There are a few situations where your lowest Mediclaim Insurance can deny your claim for cashless hospitalization. To learn more about the reasons why your claims for cashless hospitalization may be denied, read the following: 

Your paperwork is lacking in crucial information that the provider needs;

Your contact information is currently incorrect or insufficient, even though it is registered;

The medical insurance that the providers have does not cover your problem;

Their network does not include the hospital in which you're receiving care;

As the allotted period has not yet passed and your ailment falls within the category of pre-existing conditions;

if the pre-authorization request was sluggish.

There is no need to panic if your claim requests are rejected; you may still attempt to submit a claim for the expenses you incurred and submit the required paperwork. However, you must request reimbursement once the cashless health claim is denied. The reimbursement form must be completed, and any original test results, prescriptions, pharmacy invoices, and other miscellaneous items must be attached. 

The insurance company or TPA office must get this crucial component. If everything is done correctly, they usually take roughly 30 days to settle the claim. After that, the client must answer any inquiries made if there are any questions or missing documents.

How Important Is It To Have Cashless Health Insurance?

People sometimes struggle with money problems and paying medical bills effectively because of rising medical prices and emergencies like the current epidemic. Health insurance that doesn't need instant access to cash is a massive help in this situation since it will allow you to receive treatment. Be sure to receive the treatment at a hospital that is a part of the network and is listed with your health insurance company.

You'll experience mental calmness and lessen unneeded worry if you have cashless health claims providing a medical insurance policy. In addition, you'll be able to spend less time, effort, and energy negotiating the terms of your insurance claim with the business.

How To Prevent Healthcare Insurance Claim Rejection In Easy Steps?

Here is how you can ensure that your cashless health claims are not rejected

In the event of a scheduled hospitalization, the insured person must get in touch with the hospital before being admitted and submit a pre-authorization application form to the catering TPA through to the hospital TPA hub along with all pertinent policy information, the patient's ID card, and any prior medical history that may exist.

When an emergency hospitalization occurs, the policyholder goes to the closest network hospital and submits the policy-related paperwork, the processing TPA Pre-authorization request, and the request within 24 hours of the hospital admission.

Cashless payment plans may be continued in two installments: the initial permission at the admission stage, which must be between 50 and 60 percent of the desired amount, and the remaining amount at the moment of release.

The hospital could need a security deposit upon check-in, which would be refunded at check-out.

 When a pre-authorization request is rejected, the insured pays the hospital bill and submits a reimbursement request to the TPA along with the original invoices and documentation of the medical care received.

The hospital is responsible for providing the insurer/TPA with the necessary information so they can decide and authorize your cashless health claims after your admission to the hospital. However, the cashless claim may be denied if the hospital fails to give all the information the insurer/TPA requests.

How Can You Get Reimbursed If You Receive Care In A Hospital, Not Your Insurance Network, Or If A Cashless Facility Is Rejected?

Applying for a reimbursement service after the procedure has ended will allow you to get your claim reimbursed if your cashless health claims are rejected. You can request a reimbursement claim through your insurance provider by following the below steps.

Notify the insurance provider of the claim and make a note of the "Claim reference number." The claim notification form should be completed as completely as including information about the customer's hospitalization obtained directly from the source.

Provide all required documentation, including the following, to process the claim.

Complete and notarise the authentic claim form.

Valid Address verification and identification

Diagnostic procedures, medication, and consultation are recommended in the doctor's prescription.

Invoices from the pharmacy

As directed by the treating physician, including any diagnostic procedures, surgical costs, and consultations

Ambulance bill

Any paperwork necessary to evaluate the claim possible,

What Does A Health Card Mean?

A health card, which functions similarly to an identity card and is included with health insurance, is a card. Each hospital in the network that accepts this health card offers cashless hospitalization services. The name, age, insurance information, and TPA contact information are all listed on a health card.

Insured customers can call the numbers on the health card in an emergency. In addition, any network hospital will accept an e-health card, which may be obtained from the website.

After Purchasing The Policy, Can You File A Claim Right Away?

When purchasing health insurance coverage, you can only file an accident-related claim. Only after meeting the waiting period requirements outlined in the medical insurance agreement are further claims for illnesses and conditions eligible. Each health insurance coverage includes a 30-day initial waiting period that must be met before a claim can be made (not include claims relating to accidents). 

Awaiting periods for specific diseases and pre-existing conditions must also be completed by the policyholder before filing a claim. These waiting periods are added to the first waiting time.


Financial protection towards any medical crisis is essential with health insurance. Therefore, a health insurance policy should also offer a cashless facility, one of its essential components. It is due to the fact that cashless health claims make it easier to pay for medical expenses when filing a claim for health insurance.

The insurance and the hospital pay all of your medical costs in the event of cashless treatment. Simply notify the provider at least two days before a scheduled hospitalization or within 24 hours of an emergency hospitalization to use the cashless claim resolution feature.

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