What to Do If Cashless Claim is Rejected?


Cashless claims are an outstanding feature offered by most health insurance providers, allowing patients to settle hospital bills without making upfront payments at admission. Typically the Interesting Info about appealing critical illness claim.

However, sometimes cashless claims get denied for various reasons. Common among them are: 1. Make sure all information provided is accurate 2. Ensure the claim form meets requirements 3) Provide all appropriate documents

1. Ensure that all the information is correct

When filing a cashless claim, sending accurate documentation to the insurance company or TPA is essential. This includes pre-authorization forms and hospital discharge summaries. Furthermore, copies of all these documents should be kept for record keeping and future reference.

As mentioned previously, cashless claims only work at hospitals listed by your insurer or TPA. Be mindful that if there is an emergency and you end up at a non-network hospital where cashless claims will not be accepted – otherwise your claim could be denied!

Cashless claims may also be denied due to preexisting diseases not covered by your health insurance plan since many insurance providers only cover them after an agreed-upon waiting period has elapsed. As such, it is advisable that before seeking medical treatment at any hospital, you check the terms and conditions of your policy and inform TPA or insurer well in advance to ensure the smooth processing of claims.

2. Check the policy document

Insurance companies provide cashless claims as an option, paying directly to hospitals treating specific diseases/illnesses, providing that the hospital is within their network and has submitted a pre-authorization request with medical documents to the insurer.

However, cashless claims can sometimes be denied for various reasons, such as non-disclosure of material information or partial or incorrect disclosure when buying and filing coverage claims.

Please note the reasons an insurance company/TPA gives for rejecting your claim, along with all conversations with them and any documents requested (proof of residence, attestations, etc). Try disproving their reasoning by gathering any documentation/evidence to support your case and then submit all paperwork again – this should help speed up the settlement of your claim quickly! Also, keeping past medical history records may be helpful during claim settlement.

3. Contact the insurer

Insurance company phone reps are used to handling angry customers. While they wish to assist, you must remain civil and respectful during this conversation. Ensure to get their name, job title, and any recommended next steps from them as soon as possible – also, getting their contact reference number is always recommended for future reference.

If you disagree with the reasons for cashless rejection, contact the insurer directly and lodge your grievance. Make sure you bring any relevant documentation which could prove otherwise, such as policy documents.

If your cashless rejection is due to being outside their network or exceeding limits, ask them what those limits are. If you are still unsatisfied with their response, you can always contact the Insurance Ombudsman, who can investigate further – although be mindful that this could take some time! In the meantime, filing reimbursement claims is still possible, so make sure to have all original prescriptions, test reports, and pharmacy bills as proof for claims filed in this manner.

4. Contact the TPA

TPAs can only provide claim servicing by insurer guidelines and within the framework of claims settlement processes; they cannot decide to reject a claim themselves.

A reliable third-party administrator (TPA) should always strive to offer instantaneous solutions and help approve your claim while keeping records of conversations and documents. If they cannot assist, or the medical procedure was rejected because it is unnecessary, obtain opinions from licensed medical practitioners to support your case.

If your TPA denied your cashless claim due to finding it unnecessary, gather all relevant medical and doctor-prescribed details to file an appeal professionally and not emotionally, as this rejection can harm mental health. In addition, legal advice from an attorney might also prove helpful; should they refuse to work out an agreement, consider going straight to consumer court, as many insured persons have previously won against TPAs in this way.

5. Contact the hospital

Most health insurance providers now provide cashless hospitalization in their network hospitals, meaning the insured does not need to make a deposit payment upon check-in; instead, the hospital will contact their insurer directly regarding medical bills settlement.

However, sometimes your claim could get rejected for various reasons – an error in the documents submitted or lack of coverage for preexisting diseases being just two examples – so addressing them as soon as possible is vital in clearing your cashless claim quickly and smoothly.

Only send paperwork after first keeping a record. In case of rejections from insurers/TPA offices, always call or email to discuss why and how it can be corrected. Also, note what was said between you and whom to avoid forgetting any important details.

Read also: How One Can Save Up To 47 % On Your Health Insurance Right Now