Insurance & Cashless Facility

Cashless or reimbursement

There are two ways a health insurance policy pays for a hospital admission, and the difference matters to a family's cash flow rather than to the final amount.

Under cashless settlement, the hospital obtains approval from your insurer or third-party administrator before and during treatment, and the approved amount is settled directly between them and the hospital. You pay only the items the policy does not cover. This works when the hospital is in the insurer's network and the admission is notified in time.

Under reimbursement, you pay the hospital yourself and claim the amount back from the insurer afterwards, submitting the bills, discharge summary and reports. This applies when the hospital is outside the network, when cashless approval is declined, or when documentation for cashless could not be completed in time. The amount ultimately payable under the policy is the same; what changes is whether the family has to find the money first.

SIMS works with a wide range of insurers and third-party administrators — 17 of them are listed on the hospital's insurance page, including Star Health, HDFC ERGO, ICICI Lombard, Bajaj Allianz and several others. Network arrangements change, so confirm your specific insurer and policy with the insurance desk before a planned admission rather than assuming from a list.

The pre-authorisation sequence

Timelines below are the general pattern followed by most insurers. Your policy and your TPA may differ, so treat these as expectations to confirm, not guarantees.

1. Planned admission — notify well in advance

   For elective surgery or a scheduled procedure, submit your insurance details to the insurance desk several days before admission. This leaves time to obtain approval, resolve queries and tell you in advance what will not be covered.

2. Emergency admission — notify within the policy's window

   Most policies require notification of an emergency admission within about 24 hours. Treatment is never delayed for this. Inform the insurance desk as soon as the patient is stable and hand over the policy details.

3. The hospital submits the pre-authorisation request

   The treating doctor's diagnosis, proposed line of treatment, expected length of stay and estimated cost are sent to the insurer or TPA with the supporting records.

4. The insurer responds

   The response may be an approval, an approval for a lower amount than requested, a query asking for more information, or a rejection with reasons. Queries are the commonest outcome and are usually resolved within hours when the requested records are available.

5. Enhancement during a longer stay

   If treatment extends beyond the approved amount — a longer intensive care stay, an unexpected complication — the hospital submits an enhancement request. Ask for interim bills during a long admission so that nothing is a surprise at the end.

6. Final approval at discharge

   The final bill is sent for settlement and the approved amount is adjusted. You settle the non-covered items and the difference, and receive the documents you need for any subsequent claim.

Room rent limits and proportionate deduction

This is the most misunderstood clause in Indian health insurance, and the one that produces the largest unexpected bills. Many policies cap the room rent at a percentage of the sum insured per day. If you occupy a costlier room than your policy allows, some insurers reduce not just the room charge but the associated charges across the whole bill in the same proportion. The figures below are a worked illustration to show the mechanism — they are not hospital tariffs and not any particular policy's terms.

Waiting periods that commonly apply

A policy that is in force is not the same as a policy that will pay for a particular condition. These waiting periods are standard features of Indian health insurance and are the most frequent reason a claim is legitimately declined.

• An initial waiting period, typically 30 days from policy start, during which only accidental injury is covered
• A waiting period of one to two years for specified conditions such as hernia, piles, cataract, sinusitis, joint replacement, fibroids and stones, depending on the wording
• A longer waiting period, commonly two to four years, for pre-existing diseases declared at the time of taking the policy
• A separate waiting period for maternity benefit where the policy includes it at all
• Cover that lapses if a premium is missed — reinstating a policy can restart waiting periods
• Non-disclosure of a pre-existing condition when the policy was taken, which can invalidate a claim entirely

Items policies routinely do not pay for

These are usually listed as non-medical expenses in the policy schedule and are payable by the family even under an approved cashless claim.

• Registration, admission and medical records charges
• Attendant meals, extra bed and toiletries
• Gloves, masks and certain disposables, depending on the insurer's non-payable list
• Telephone, television and laundry charges
• Nutritional supplements and items not directly related to the treatment
• Treatment taken as an outpatient, where the policy has no outpatient benefit
• Preventive health check packages, unless a specific policy benefit applies
• Cosmetic procedures and treatments excluded by the policy wording

What to bring to the insurance desk

• The insurance card or e-card, and the policy number
• Photo identity proof of the patient — the name must match the policy record
• The full policy document, or at least the schedule showing the sum insured, room rent limit and co-payment clause
• Contact details of your insurer or TPA, including the claim helpline number
• Referral or prescription for the planned admission from the treating doctor
• Records of any pre-existing condition, and the date it was first diagnosed
• For a corporate policy, the employee identity card and the employer's group policy details
• For a claim on a second policy, the details of the first insurer and any settlement already made

Common questions