Cashless mediclaim – are you paying more than you should?

Facing a medical problem is a trauma, that is a drain on physical, emotional as well as financial health. Thanks to cashless medical claim facility, that takes care of the financial aspect (how much does it take care is a topic left for another day).

Many heath insurance policies come with the co-payment option for the want of lower premium. Co-payment is the payment that the insured agrees to make in the event of a claim. For example a policy can come with 10% co-payment, which means that the insured shall pay 10% of the total expenses while insurer shall pay 90%.

The Process – During discharge process, the bills are sent to TPA or Insurance company’s (IC) helpdesk for clearance on bills. While approving the amount, TPA/IC computes the co-payment amount.  This amount is collected by hospital directly from insured. Consumables used during the treatment, are not payable as part of the claim and are also recovered from the insured.

This is where the insured has to be extremely vigilant. The insured should be paying for consumables and co-payment percentage of the remaining amount, rather than paying co-payment on whole amount and consumables in addition to that.

Let’s use an example to understand the difference. Let’s assume that Amit’s father has been hospitalized and after spending couple of days in hospital, the total bill is ₹ 5,00,000 (Five lacs only). Let us also assume that the co-payment that Amit opted for while buying health insurance is 10%. This means that Amit is liable to pay ₹ 50,000 while insurance company is liable to pay ₹ 4,50,000. This is also specified when the approval is received by hospital for cashless settlement. Let us also assume here that in the bill of ₹ 5,00,000, ₹ 1,00,000 is consumables (the amount assumed is higher to analyze the impact of this).

Insured might be asked to pay the amount as follows ₹ 50,000 (co-payment) + ₹ 1,00,000 (for consumables). Thus total amount payable is ₹ 1,50,000, however, the actual amount should computed as follows

(A) Bill Amount = ₹ 5,00,000

(B) Consumables = ₹ 1,00,000 (to be paid by insured)

(C) Balance amount (A-B) = ₹ 4,00,000

(D) To be paid as part of co-payment (10% of C above) = ₹ 40,000

(E) Total amount to be paid by insured = ₹ 1,40,000

Savings in comparison with previous calculation = ₹ 1,50,000 – ₹ 1,40,000 = ₹ 10,000.

It is thus highly recommended to be vigilant at the time of claim settlement to ensure that hospital is not fleecing.



2 thoughts on “Cashless mediclaim – are you paying more than you should?

  1. sonali

    When in hospital, the word discharge itself brings so much happiness that we forget to check such simple things, worst still we are the educated lot….nice write up….but I hope I never have to use this piece of information….😊


Leave a Reply

Fill in your details below or click an icon to log in: Logo

You are commenting using your account. Log Out /  Change )

Google photo

You are commenting using your Google account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s