Know how network, non-network hospitals affect your health claim

Thus, knowing how expensive hospitalization and treatment is, it is wise to purchase a health insurance policy and understand the role of hospitals, which play a vital role in settlement of claims. We often overlook the meaning of non-network hospitals and network hospitals in health insurance until one is hospitalized and a claim is made.

Network Hospital vs. Non-Network Hospital

When you buy a comprehensive health insurance plan, the insurance company provides you with an in-network hospital list. There is a tie-up between insurance companies and the mentioned network hospitals which provides the benefit of cashless hospitalization to the policyholder.

Amit Chhabra, Head of Health Insurance, Policybazaar.com said that there is no need to worry about preparing money at the last minute while getting treatment from a network hospital. The health insurer directly settles the hospital bills, thereby taking the burden off the shoulders of the policyholder.

“Whereas, if you choose to get treatment from a non-network hospital, then all the expenses will be borne by you at that time, and you will get reimbursed for the same later,” he said.

How do network hospitals work?

In case of planned hospitalization, the network hospital and the insurance company are informed about the hospitalization in advance. Thereafter, the policyholder or his dependents will have to file a pre-authorization form available at the Insurance Desk of each hospital for redressal of insurance and cashless claims related queries. You can also download and obtain a printout of the document from the website of the Third-Party Administrator (TPA). After filling the form the insured is admitted.

After submitting the form, the hospital will verify the details and inform your insurance company about the claim. Once your insurance company accepts the claim request, it will send an authorization letter to the hospital stating the amount for the medical procedure. After that, the claim amount is paid by your insurer directly to the hospital. This process takes around 30 minutes to 2 hours depending on the insurer.

impact on health claims

Now, let’s say the hospitalization is unplanned, and you are hospitalized.

case 1: When Patient ‘A’ is admitted to a network hospital, the insurance company will take care of all the expenses, and the patient can avail the cashless claim facility with the help of a third party administrator. ‘A’ will pay certain expenses for the components required for the treatment, which are not mentioned in the policy. After that, documents are collected for other records.

Chhabra said, “The insured need not pay a penny to the hospital in case of hospitalization during medical emergency (there may be exceptions for specific treatment as per your policy) when admitted to these network hospitals. Medical expenses for such services are usually justified as hospitals have to incur an increase in the number of patients due to the insurer.”

Case 2: When Patient ‘A’ is admitted to a non-network hospital, it is difficult for him/her to take full advantage of the health insurance policy.

Atur Thakkar, Co-Founder and Director, Alliance Insurance Brokers said, “The policyholder can file a claim for reimbursement after complete medical treatment and after deducting the medical expenses out of pocket. However, it is necessary to submit all the original supporting documents like treatment report, medical invoice etc. After that the documents are verified. And, as per the underwriting policy, the policyholder gets the reimbursement amount.”

Rakesh Goyal, Director, Probus Insurance said, “The reimbursement process usually comes with a waiting period of 10 to 15 days, in which the insurer verifies the documents submitted and then approves the claim; If everything looks good.”

what should you do

In the case of non-network hospitals, there is a possibility that the insurance company may not cover certain expenses that are reasonable and reasonable to be allowed under the terms of the policy. Thus, to get a speedy claim settlement process, especially if it is an unplanned treatment, you should always check the list of network hospitals that are accessible to you and get yourself treated there.

Ajay Shah, Director and Head, Retail Business, Care Health Insurance, said, “In case of network hospitals, the insured has the advantage of cashless hospitalization. This, in turn, means they have to provide paperwork to file a claim. There is no need to go through the lengthy process of compiling and filing the action.”

Moreover, there is no waiting period associated with such cashless claims and avoids the tedious submission process of documents, bills etc., which would otherwise be mandatory during the reimbursement process.

Goyal further added, “It is highly suggested to look for network hospitals while buying a health insurance plan as it saves you the hassle of reimbursement process (which can happen if you go for non-network hospitals). One should opt for non-network hospitals only if the required treatment is not available in any network hospital.