1️⃣ Identify a Network Hospital

You must choose a hospital that is part of Care’s cashless hospital network.

Why this matters:

• Only network hospitals can offer cashless treatment

• Non-network hospital = reimbursement only

2️⃣ Pre-Authorisation Request (Pre-Auth Form)

What happens:

• Hospital (TPA desk) fills a pre-authorisation form

It Contains:
Diagnosis
Proposed treatment
Estimated cost
Past medical history (PED)

Who fills it:

• Hospital fills medical part

• You sign consent and declaration

Why critical:

This is the first medical scrutiny by insurer.
Any mismatch here can lead to:

• Partial approval

• Rejection

• Later deduction at discharge

3️⃣ Hospital Sends Request to Insurer

Timeline:

• Planned hospitalisation: before admission

• Emergency: within 24 hours of admission

What insurer checks:

• Policy validity

• Sum insured

• Waiting periods

• PED disclosures

• Exclusions

• Room rent eligibility

• Sub-limits (if any)

4️⃣ Insurer Reviews & Approves (or Queries)

Possible outcomes:

✔ Approved – Full or partial amount sanctioned
⚠ Query raised – More documents needed
❌ Rejected – Due to exclusion, waiting period, non-disclosure

Important truth:
Pre-auth approval ≠ final approval
Final settlement happens after discharge.

5️⃣ Treatment, Discharge & Final Bill

What happens:

• Hospital treats you

• At discharge:

  • Final bill is sent to insurer

  • Insurer deducts non-payable items

Insurer pays:

• Approved admissible expenses directly to hospital
  
  

6️⃣ You Pay Non-Covered Costs

This may include:

• Non-medical items (unless Claim Shield add-on)

• Higher room category difference

• Consumables not covered

• Deductibles / co-pay (if applicable)

This is normal and legal.

DUTIES OF CLAIMANT – CASHLESS (VERY IMPORTANT)

If you fail here, claim can be rejected even if illness is genuine.

✔ Provide Accurate Medical History

• Declare diabetes, BP, asthma, past surgeries, etc.

• Non-disclosure = claim repudiation
  
  

✔ Submit Correct Documents

• Policy copy

• KYC

• Photo ID

• Signed consent

✔ Inform Insurer Timely

• Planned: before admission

• Emergency: within 24 hours

1️⃣ Get Treated & Pay Hospital Yourself

You pay 100% upfront.

Insurer reimburses later only admissible expenses.

2️⃣ Collect All Documents (MOST IMPORTANT STEP)

You must collect:

• Original bills

• Payment receipts

• Discharge summary

• Prescriptions

• Investigation reports

If you miss originals → claim may fail.

3️⃣ Submit Claim Form & Documents

Timeline:
Usually 15–30 days from discharge (check policy)

Submission includes:

• Claim form (signed)

• Originals or insurer-accepted copies

• Policy details

• Bank details

4️⃣ Insurer Assesses Claim

They verify:

• Diagnosis vs coverage

• Waiting periods

• PED disclosure

• Exclusions

• Reasonableness of charges

They may:

• Ask for clarification

• Call hospital

• Seek additional documents

5️⃣ Reimbursement Paid to Bank Account

• Only approved admissible amount

• Paid directly to insured’s bank account

Time: Typically 7–21 working days after approval

DUTIES OF CLAIMANT – REIMBURSEMENT

✔ Preserve Originals

• Bills

• Receipts

• Reports

✔ Submit Within Time Limit

Late submission = rejection risk

✔ Correct Bank Details

Wrong IFSC / account = payment delay