Why a cashless claim may require you to pay?

In a standard medical policy, the insured pays the hospital bill by himself then claims for reimbursement from the insurer.

On the other hand, in a cashless claim, the policyholder is not expected to pay the hospital bills as the insurer reimburses the same directly to the hospital

Well, that is how it works in theory. However, there may be instances when you have to pay the bill out of your pocket even in a cashless claim. Wondering why this happens? Why should the insured pay some fraction of the medical expenses at the time of discharge? Here’s why.

Exclusions

Most insurance policies do not cover all the medical expenses. Therefore, there are deductions because of non-admissible items or services when claiming medical insurance. For example, admission fee, registration charge, medical record fee, insurance processing fee, etc. are non-admissible and have to be borne by the patient out of their pocket. It won’t be covered by the insurer.

Room rent limit

You won’t believe this but room rents are capped. This means that an upper-limit is set on the room rent. If the room you have chosen has a higher rent, the insurer will only pay the standard room rent. The extra charges on the room will have to be borne by the policyholder.

Sub-limit on treatments

It is a really common assumption that if your total treatment price is a smaller amount than the total insured, it'll be included in the policy. In reality, virtually each treatment incorporates a limit applied to that. And if the treatment price exceeds the limit, you may have to pay the difference.