Admitted in non-network hospital? Know your insurance cover

The pandemic has demonstrated the significance of health insurance. Generally, we prefer cashless facility as there is no need to deposit any cash in the hospital. The insurer generally pays the hospital directly through TPA. But what happens if a person has to be treated at a non-network hospital? Does the health insurance policy help in such a situation and, if yes, then how do they help a person out?

The health insurance policy works in a non-network hospital also but not as smoothly as one might experience at a network hospital. Here are few points which may be important for you.

Network hospitals

Every insurance company has a list of multiple hospitals, clinics etc. Which generally charge a lower fee for their policyholders than others. And, in return, hospitals get more patients who are channeled to them through the insurance company’s network.

Every health insurance company has a list of network hospitals which offers cashless facility. No cash payment is needed for treatment in these hospitals since the amount would be given by the insurance company itself to the hospital.

Non-network hospitals

If a patient is admitted to a hospital which is not in the list of the insurance company, then it called non-network hospital. In non-network hospitals no cashless facility is available and the patient has to bear all the expenses.

After that they can file a claim and if everything is all right, the insurance company might reimburse the person between 60-70% of the total bill amount. It could also be higher if all the documents required by the insurance company are provided and accepted by the insurer,

How it works

In emergency situation we are often not in a position to check which hospitals are in the TPA list.

When a person is admitted to a non-network hospital, he/she has to pay the full cost of treatment first. Then they can submit all the treatment-related documents to the insurance provider to claim for a reimbursement.

After checking all the documents the insurance company refunds the amount to the policyholder in 10-12 days.

But it is difficult for him to get about 90% expenses from the insurer. But one may get 60%-70% from the insurance company if the person is treated at a non network hospital.

The process

The process of getting reimbursements is a bit complicated if one avails treatment in a non-network hospital. The policyholder first files a claim for reimbursement after the entire medical treatment is over. It is done in a prescribed format that the insurance company provides.

But the person has to pay out from the pocket first. The policyholder needs to submit his/her claim form with the all medical records, relevant bills, and KYC documents.

It is necessary to submit all the original and supporting documents. The documents would be available from the hospital.

After checking all the documents and according to the rules and regulations of the existing policy, the amount is refunded to the policyholder as per the claim settlement rules. But this amount rarely exceeds 70% of the total bill amount, confirmed experts.

But cashless facility is not available in the non-network hospitals.