Cashless Mediclaim – A First Person Narrative

In March this year I had a thymectomy – surgery to remove my thymus gland. The procedure was paid via cashless mediclaim. I thought sharing my experience with ‘cashless’ might be useful to other readers.

My hospitalization was planned. That is I had plenty of time (5-6 weeks) to plan my hospital stay from the moment it was decided to go ahead with the surgery. Sometimes one has only a few days depending on the procedure. Even for such cases the patient and his/her attendant have the time to get all insurance particulars in order, approach the hospital and get the stay approved by the insurer for cashless payment via the hospital.

Photo by Pete (flickr)
Photo by Pete (flickr)

Cashless claim for emergency hospitalization is a different ball game. In this case the patient can do nothing to help with the paperwork and procedures. To avail cashless mediclaim, the insurance particulars have to be located. This may not always be possible (road accidents, hiking accidents and sometimes even in the office or home). Cashless mode cannot be relied upon for emergencies.

Once I made up my mind about the surgery and the family agreed on a date, I approached the insurance department of the hospital and obtained a cashless pre-authorization form. I also found out the room tariffs and the approximate cost of the procedure.

Thymectomies are relatively less common procedures. So I was given a ball park estimate of costs. Next I went to the surgeon and asked him to fill out the form and sign it. My policy has sub-limits on room rent (1% of the sum insured) and ICU rent (2% of SI). Since I had increased the sum insured each year for the last 5 years, I could afford the deluxe room which was more than comfortable for me and my brother-in-law who stayed with me (regular readers will know that this is not the first time he has helped me. He is a fantastic guy).

The insurance department wanted me to report with the pre-authorization form, PAN card copy, insurance policy copy and all relevant medical records two days before the surgery. In case the cashless claim was not approved, I moved around my emergency funds so that I have enough cash ready.

When I went to submit my application, I was interviewed by a doctor who is employed full time in the insurance department. I learnt something very important from her. My current SI is Rs. 5 Lakhs. When I was diagnosed with Myasthenia Gravis (the reason I needed the thymectomy), my cover was Rs. 4.5 Lakhs. This means that for the next two years (according to my policy) any hospitalization arising from Myasthenia will have a limit of Rs. 4.5 Lakhs and not Rs. 5 Lakhs. It is treated as a pre-existing disease and the rules that applied when the policy started also apply here!

 This is a very important reason why we should increase the SI as much as possible for all family members each year. If I had left my initial SI of Rs. 1 Lakhs unchanged, my cashless application would have been rejected. The doctor in the insurance department reviewed my medical records and was satisfied that everything was in order.

I was told that my application would be forward to the TPA (third party administrator) and that it will take 8-12 hours for a response. I called back the next day and found that my application was accepted and that the TPA had approved about 50-60% of the expected total cost initially. Since I was getting admitted on a Sunday, I made sure that the insurance department would be open that day!

When I got admitted, the reception checked with the insurance department and my admission was approved. I had to pay a small fee for registration. I was in hospital for 3 nights. Thanks to an extremely competent doctor and support staff, my stay was quite pleasant!

 Although the medicines and other costs were covered under the cashless scheme, we still had to pay a few thousands for miscellaneous items like gloves certain types of dressing material etc. So it is important to keep cash/card ready all the time.

 Discharge after a cashless hospital stay can be time consuming. The discharge summary and all other records go to the insurance department to be forwarded to the TPA. The TPA takes a few hours to approve the remaining cost of the surgery and clear the discharge. If there is an issue (there wasn’t in my case) then we will have to be prepared for a delay and if necessary shell out some cash. This can later be claimed via reimbursement.

 In my case, the actual cost was lower than the estimate the hospital gave. Probably why the discharge went smooth! Probably why the hospital is part of the preferred network hospital of the TPA!

Of course choosing the doctor is more important than choosing the hospital. If a competent doctor works in a non-network hospital we must be ready to pay for hospital expenses and later apply for reimbursement.

My doctor does about 4 heart surgeries a day. He could have cut me open across my ribs, removed my thymus in 45 minutes and moved on to the next operation. Instead,he chose a minimally invasive procedure with 3 holes on the side of my chest. The operation lasted (I am told) more than two hours. The 45 minute operation meant 2-3 weeks recovery. The two hour operation meant a recovery of 2-3 days!  Thanks to him, I practically had no pain!

Policy: United India Platinum Cover (individual covers for each member)

TPA:  TTK HealthCare.

Although I am quite happy with the policy, I must admit that when I purchased it I knew nothing about such policies and personal finance.

What are your views on cashless mediclaim?

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71 thoughts on “Cashless Mediclaim – A First Person Narrative

  1. Mohit Pandey

    Good Morning Pattu, thanks for sharing the experience. Cashless is the best part of health insurance, it removes the struggle of claims. I purchased health insurance policy for my parents directly from Insurance company and there is no TPA.

    Reply
  2. Mohit Pandey

    Good Morning Pattu, thanks for sharing the experience. Cashless is the best part of health insurance, it removes the struggle of claims. I purchased health insurance policy for my parents directly from Insurance company and there is no TPA.

    Reply
  3. bharat shah

    thank you for sharing. you mentioned insurance department. i guess it belongs to the hospital. we got insured by UIIC , but TPA is Meditek . we got 4-5 claims in 15-20 yrs , but of smaller a/m and not Cashless. took sometime a lot time and required follow up, otherwise faced not more problems.

    Reply
  4. bharat shah

    thank you for sharing. you mentioned insurance department. i guess it belongs to the hospital. we got insured by UIIC , but TPA is Meditek . we got 4-5 claims in 15-20 yrs , but of smaller a/m and not Cashless. took sometime a lot time and required follow up, otherwise faced not more problems.

    Reply
    1. pattu

      Yes that is the impression we get. But it does involve some running around. If we have enough time to prepare that should not be a problem.

      Reply
    1. pattu

      Yes that is the impression we get. But it does involve some running around. If we have enough time to prepare that should not be a problem.

      Reply
  5. Srikanth Matrubai

    Thanks for the amazing post Pattu.
    By the way you have not mentioned the name of the hospital.
    Also, did you enquire how much time it would have taken for the Cashless if it was an unplanned Operation?

    Reply
  6. Srikanth Matrubai

    Thanks for the amazing post Pattu.
    By the way you have not mentioned the name of the hospital.
    Also, did you enquire how much time it would have taken for the Cashless if it was an unplanned Operation?

    Reply
  7. Rakesh

    Dear Pattu,

    Thanks for sharing your personal experience in a very detailed manner. Will be helpful for everyone.
    Appreciate your work.

    Reply
  8. Rakesh

    Dear Pattu,

    Thanks for sharing your personal experience in a very detailed manner. Will be helpful for everyone.
    Appreciate your work.

    Reply
  9. dilip

    Very useful post as usual. I need some clarification sir.unlike many instead of health insurance policy we have company hospital. Here medium level facilities are available and for further treatment we are referred to all well known govt and private hospital. This facility covers my family and no restriction on amount but facilities depend on grade.still do I need to take health insurance. If so whether it should be family floater or individual plans

    Reply
    1. pattu

      Thank you. I also have a institute hospital and similar referral system. I don't use since the doctors I am comfortable with are not part of it.

      I strongly advice you to get your own individual plan for all dependents in the family. Because the kind of group insurance you may have is variable each year. If you get a health cover now and continue it for the rest of your life, it will be cheaper and more flexible in the long run.

      Best to get health insurance as early as possible in life.

      Reply
  10. dilip

    Very useful post as usual. I need some clarification sir.unlike many instead of health insurance policy we have company hospital. Here medium level facilities are available and for further treatment we are referred to all well known govt and private hospital. This facility covers my family and no restriction on amount but facilities depend on grade.still do I need to take health insurance. If so whether it should be family floater or individual plans

    Reply
    1. pattu

      Thank you. I also have a institute hospital and similar referral system. I don't use since the doctors I am comfortable with are not part of it.

      I strongly advice you to get your own individual plan for all dependents in the family. Because the kind of group insurance you may have is variable each year. If you get a health cover now and continue it for the rest of your life, it will be cheaper and more flexible in the long run.

      Best to get health insurance as early as possible in life.

      Reply
  11. AyushP306

    It was good to hear about your experience with the cashless mediclaim. Well the good thing is that the surgery is over safely. I wish you a speedy recovery. Take care.

    Reply
  12. AyushP306

    It was good to hear about your experience with the cashless mediclaim. Well the good thing is that the surgery is over safely. I wish you a speedy recovery. Take care.

    Reply
  13. dilip

    sir
    you are not comfortable with private insureance companies in case of term insurance.what 's your call on health insurance from private co.s? what about medimanage?

    Reply
    1. pattu

      Hi Dilip, I am not comfortable with private health insurers also. Medimanage is doing a good job. However if a person can take an informed decision on their own, they do not need them. They do help in claim settlement. But if there is an issue with a claim and insurer does not pay, them no one can do anything.

      Reply
  14. dilip

    sir
    you are not comfortable with private insureance companies in case of term insurance.what 's your call on health insurance from private co.s? what about medimanage?

    Reply
    1. pattu

      Hi Dilip, I am not comfortable with private health insurers also. Medimanage is doing a good job. However if a person can take an informed decision on their own, they do not need them. They do help in claim settlement. But if there is an issue with a claim and insurer does not pay, them no one can do anything.

      Reply
  15. A.Sundaram

    Dear Pattu,
    "If I had left my initial SI of Rs. 1 Lakhs unchanged, my cashless application would have been rejected" - Could you please elaborate on this?Why would the cashless facility be denied just because the SI is only Rs.1 Lakh(you had already completed the wait for PED). Or is it because of the sub-limit for room-rent?Thanks for the clarification.

    Reply
    1. pattu

      PED clause continues throughout the policy. If a person becomes diabetic 5 years after getting a policy and SI at that is Rs. 1 lakhs, diabetes related hospitalization will have a limit of 1 lakh until the duration for PED lapses (2/3 years from date of diagnosis).

      That is if the SI is Rs. 3 lakh in the 6th year, for diabetes related hosp. only 1 lakh will be allowed.

      So if we keep increasing SI each year, the SI at the time of detection of a disease will be high.

      My cashless application for more than 1 lakh. So it would have been rejected had I not increased the SI. This is because the SI at the time of diagnosis would have been Rs. 1 lakh. Yes the insurer would have accepted for 1 lakh but the hospital would make me pay upfront and that would have been troublesome.

      Reply
  16. A.Sundaram

    Dear Pattu,
    "If I had left my initial SI of Rs. 1 Lakhs unchanged, my cashless application would have been rejected" - Could you please elaborate on this?Why would the cashless facility be denied just because the SI is only Rs.1 Lakh(you had already completed the wait for PED). Or is it because of the sub-limit for room-rent?Thanks for the clarification.

    Reply
    1. pattu

      PED clause continues throughout the policy. If a person becomes diabetic 5 years after getting a policy and SI at that is Rs. 1 lakhs, diabetes related hospitalization will have a limit of 1 lakh until the duration for PED lapses (2/3 years from date of diagnosis).

      That is if the SI is Rs. 3 lakh in the 6th year, for diabetes related hosp. only 1 lakh will be allowed.

      So if we keep increasing SI each year, the SI at the time of detection of a disease will be high.

      My cashless application for more than 1 lakh. So it would have been rejected had I not increased the SI. This is because the SI at the time of diagnosis would have been Rs. 1 lakh. Yes the insurer would have accepted for 1 lakh but the hospital would make me pay upfront and that would have been troublesome.

      Reply
  17. Syamantak

    Dear Pattu,

    Sorry for opening this thread after so long. I somehow missed this (may be because I thought medical insurance is not my priority, I got my company group policy. how dumb I was 6 months back!!!). I just landed up here from the link in today's post

    What benefit do you get if you have individual covers, for each of the family than a family floater? I felt individual policies are more costly and less cost effective since I can have handsome savings and can opt a higher SI if I go for Family Floaters

    I recently opted for a family floater and I am yet to complete the formalities. I might as well reject the cover if I see an individual cover is more beneficial.

    Reply
    1. pattu

      Yes, floaters are cost-effective. Somehow I am uncomfortable with them. The way I see it, floaters will work if the members are all healthy. Once the individuals have diseases then the loading applies to everyone. In my case only my premium was loaded.
      Also once members age, the probability of two people in the policy getting hospitalized in the same year increases.
      So I prefer individual policies.
      Don't change your policy now. Down the line, when your income increases, you can shift to an individual policy with the same insurer after discussing this possibility with them.

      Reply
    2. A.Sundaram

      Dear Syamantak,

      A suggestion(Disclosure:I have done it for myself)-

      My daughter and I have individual policies with SI of 3L and 5L resp. which I have topped with a floater cover of 10 L covering both of us(this top-up floater is very cost-effective). Add to these,the accumulated NCBs and we have a decent cover(I sincerely hope!). If you find merit in this,you may think along these lines.

      Reply
  18. Syamantak

    Dear Pattu,

    Sorry for opening this thread after so long. I somehow missed this (may be because I thought medical insurance is not my priority, I got my company group policy. how dumb I was 6 months back!!!). I just landed up here from the link in today's post

    What benefit do you get if you have individual covers, for each of the family than a family floater? I felt individual policies are more costly and less cost effective since I can have handsome savings and can opt a higher SI if I go for Family Floaters

    I recently opted for a family floater and I am yet to complete the formalities. I might as well reject the cover if I see an individual cover is more beneficial.

    Reply
    1. pattu

      Yes, floaters are cost-effective. Somehow I am uncomfortable with them. The way I see it, floaters will work if the members are all healthy. Once the individuals have diseases then the loading applies to everyone. In my case only my premium was loaded.
      Also once members age, the probability of two people in the policy getting hospitalized in the same year increases.
      So I prefer individual policies.
      Don't change your policy now. Down the line, when your income increases, you can shift to an individual policy with the same insurer after discussing this possibility with them.

      Reply
    2. A.Sundaram

      Dear Syamantak,

      A suggestion(Disclosure:I have done it for myself)-

      My daughter and I have individual policies with SI of 3L and 5L resp. which I have topped with a floater cover of 10 L covering both of us(this top-up floater is very cost-effective). Add to these,the accumulated NCBs and we have a decent cover(I sincerely hope!). If you find merit in this,you may think along these lines.

      Reply
  19. Syamantak

    Thats indeed a good Suggestion Sundaram ji.. In my case I'd then be topping up my FLotaer with individual policies. Since I got a group cover from my employer (around 4L), I picked up a 7L cover for me my wife and my 1.5 yrs old daughter.
    I might look at the option you suggested after I touch the 36 yrs slab..

    Reply
  20. Syamantak

    Thats indeed a good Suggestion Sundaram ji.. In my case I'd then be topping up my FLotaer with individual policies. Since I got a group cover from my employer (around 4L), I picked up a 7L cover for me my wife and my 1.5 yrs old daughter.
    I might look at the option you suggested after I touch the 36 yrs slab..

    Reply
  21. A.Sundaram

    Dear Syamantak,

    Now that you have an idea,I'm sure you'll work out a good strategy for yourself.Good Luck and let's pray that you have to NEVER utilise your mediclaim 🙂

    Reply
  22. A.Sundaram

    Dear Syamantak,

    Now that you have an idea,I'm sure you'll work out a good strategy for yourself.Good Luck and let's pray that you have to NEVER utilise your mediclaim 🙂

    Reply
  23. venkat

    Hi Pattu, i am a novice at this so please any advice welcome. Are there any insurance plans which cover (even partially) PED - pre-existing diseases? I am thinking of taking a plan but there are some existing issues for family members and wherever I check, i see the plans - even for young folks - mention a minimum of 3/4 years before they can be used for any PED reimbursement.

    Reply

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