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Network and Non-Network Hospitals – How They Affect Health Insurance Claims?

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Published on August 18, 2021. EST READ TIME: 3 minutes

Medical emergencies are among the biggest uncertainties you can face in life. And health insurance is the best way to stay financially prepared against that. A health plan offers many benefits to policyholders, a major one being cashless treatment facility at network hospitals. This means that you can avail cashless treatment at the hospitals with which your insurance company has a tie-up. This saves you from filing a reimbursement claim with the insurer and many other hassles, such as arranging cash and cumbersome paperwork.

An insurance company usually has many network hospitals spread across the country. So, you can easily find some good ones in the vicinity if you go for the best Mediclaim policy for family or self. Also, when taking health insurance, you must opt for an insurer with a vast network of reputed hospitals.

What are the differences between network and non-network hospitals?

Here are the main differences between network and non-network hospitals:

1. Meaning:

   The list of hospitals with which a health insurance company has tie-ups are known as network hospitals. You can check the list when taking health insurance. Opting for an insurer with at least some network hospitals around your place of residence is always a good idea.

   Non-network hospitals are those that do not have any prior contract with the insurer for cashless treatment of the policyholder.

2. Treatment:

   You can avail cashless treatment at network hospitals, subject to policy terms and conditions.

   Non-network hospitals do not offer cashless treatment facility. You need to pay the bills from your own pocket and then file a reimbursement claim with the insurer.

3. Formalities:

   Availing cashless treatment at a network hospital saves you from the formalities of filing a reimbursement claim with the insurance company. All you need to do is show your health insurance card at the network hospital and the insurer will take care of the rest.

   Treatment at a non-network hospital comes with many formalities. This includes paying the hospital bills, filling the reimbursement claim form, and submitting the discharge summary and hospital bills to the insurance company. This can be a lengthy and tedious process.

4. Claim settlement:

   When getting treated at a network hospital, you won’t have to worry about the claim settlement process. The insurer will get in touch with the hospital and take care of all the formalities. Also, you won’t need to spend anything from your pocket. 
   For treatment at a non-network hospital, the claim settlement depends on the insurance company and the documents you submit. The insurer will check all your bills and documents and approve whatever it finds correct and reasonable. So, the chances of losing some money are high. The claim is usually settled within 10-15 days.

Do network and non-network hospitals affect your health plan’s premium?

No, network and non-network hospitals will not affect your health plan’s premium. However, the claim process is different for both. Also, the claim gets affected depending on where you get hospitalised for the medical procedure. The following scenarios will help you understand the same:

Scenario 1: Network hospital does not offer cashless facility

Some network hospitals may not offer cashless facility to policyholders. If you get treated in any such hospital, you need to settle the bills from your own pocket at the time of discharge. You should then file a claim with the insurer and submit your discharge summary, bills and other necessary documents. After verifying the bills, the insurer will reimburse the amount that it finds suitable as per policy terms and conditions.

Scenario 2: Network hospital offers cashless claim facility

If you avail treatment at a network hospital that offers cashless claim facility, the claim settlement is quite easy. All you need to do is present your health card at the time of admission to the hospital and the pre-authorisation form at the hospital desk. You must also inform the TPA or third-party administrator about your hospitalisation. The TPA will collect necessary bills and documents directly from the hospital and settle your hospitalisation costs. You won’t have to pay for anything other than for the expenses not covered under your health plan.

Scenario 3: Treatment at a non-network hospital

If you opt for a medical procedure at a non-network hospital, you must settle hospital bills from your pocket during discharge. Later, you can approach the insurance company and file a reimbursement claim with them. For this, you need to fill and submit the reimbursement claim form along with the discharge summary, hospital bills and other necessary documents. The insurer will verify all the bills and approve only those expenses that are covered under your health plan. At times, insurance companies may approve a partial bill amount stating that the hospital’s expenses were on the higher side. Hence, you will need to pay the difference from your pocket.

HDFC ERGO offers nearly 10000+ network hospitals across India

If you are looking for the or self with a long list of network hospitals, HDFC ERGO health insurance is just right. The insurer’s list includes some of the world-class hospitals offering the finest treatment. Hence, buying HDFC ERGO health insurance will help you avail the best medical facilities during emergencies and keep you and your loved ones at peace.

Conclusion

When you have a health plan, it is always better to choose a network hospital for any kind of medical procedure. Hence, be aware of the network hospitals in your vicinity or keep a list handy for emergency situations. Also remember that in case of pre-planned hospitalisation, you must get in touch with TPA for necessary formalities and cashless claim approval. After the initial formalities, the insurer will take care of your hospital bills and save you from unnecessary worries and hassles.

Disclaimer: The above information is for illustrative purpose only. For more details, please refer to policy wordings and prospectus before concluding the sales.

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