Cashless vs. Reimbursement Claims
Health insurance claims operate under two mechanisms:
1. Cashless Settlement: The hospital coordinates directly with your insurance company or Third Party Administrator (TPA). You only pay for non-medical consumables, while the insurer settles eligible medical costs directly.
2. Reimbursement: You pay the hospital bills out of pocket and submit original documentation to the insurer post-discharge for refund into your bank account.
The 4-Step Cashless Hospitalization Workflow
Step 1: Hospital TPA Desk — Present your Health Card / Policy Copy and Patient ID Proof (Aadhaar/PAN).
Step 2: Pre-Authorization Request — The hospital TPA desk faxes the estimated treatment cost and diagnosis form to the insurer.
Step 3: Initial Approval — The insurer issues initial authorization within 2 to 4 hours.
Step 4: Final Discharge Authorization — Upon discharge, final itemized bills are sent for conclusive clearance.
Mandatory Reimbursement Documents Checklist
Always preserve and submit:
• Duly signed and filled Claim Form Part A (by insured) and Part B (by treating hospital).
• Original Discharge Summary detailing admission history and clinical notes.
• Original itemized final hospital bill with paid receipts.
• Doctor's prescription notes and original pharmacy bills.
• Diagnostic test reports (X-rays, MRI, blood work) and doctor referrals.
• Cancelled cheque with printed name of the primary policyholder.
Top 4 Reasons Health Claims Get Delayed or Rejected
1. Non-Disclosure: Failing to declare prior surgeries, hypertension, or diabetes during initial policy purchase.
2. Active Waiting Periods: Claiming for specific ailments (e.g. hernia, joint replacement) before their 2-year waiting period expires.
3. Hospitalization solely for diagnostics without active clinical treatment.
4. Excluded expenses: Non-payable items like gloves, masks, registration charges, and food expenses.
How VestiFi Stands By You During Claims
You never have to navigate claim bureaucracy alone. Sunil Srivastava assists VestiFi clients by reviewing documentation, liaising with insurer claim desks, and ensuring fast-track settlement.