Quick Summary
This article covers everything you need to know about network hospitals and non-network hospitals to make informed decisions during health emergencies.
Over the years we have seen health insurance costs skyrocketing irrespective of metro and non-metro cities. . It was common that private medical hospitals were charging higher for patients having health insurance coverage compared to those who don’t. Neither insurance policyholders nor the insurers loved this.
In order to prevent this, health insurance providers tie-up with different hospitals across the country and include them in their “Network Hospital”.
This enabled two things -
☝️ Standardized pricing
✌️ Easy payments for policyholders.
This article covers everything you need to know about network hospitals and non-network hospitals to make informed decisions during health emergencies.
What is a network hospital in health insurance?
Every insurance carrier ties-up with a list of hospitals across the country. These hospitals are called the network hospitals of the particular insurer. You can generally find the list of network hospitals of a particular insurer on their website.
💡 The fundamental advantage of network hospitals is the cashless claim facilities for the policyholders.
For instance, if you fall sick and get admitted to any of the listed hospitals (network hospitals), then you do not have to worry about any cash costs. Here your insurance carrier takes complete responsibility for bearing up the cost and directly settles with the hospital.
Read: Top general health insurance companies in India
What is a non- network hospital in health insurance?
The hospitals that are not listed under the contract while issuing insurance from an insurance carrier are referred to non-network hospitals.
💡 Mind you, non-network hospitals do not provide health insurance policyholders with the benefit of cashless claim facilities.
For instance, if there is an emergency and you have to go to a non-network hospital, you will be responsible for paying the medical bills all by yourself. You can only claim the costs after you meet the necessary documentation formalities for reimbursement.
Read: GIPSA, PPN and empanelment
Understanding the difference between Network and Non-Network Hospitals through different scenarios
Scenario 1 - Network hospital and cashless claim
Let’s break it down how a cashless claim works at a network hospital with a simple example.
Example: Ms. Seema catches a viral flu and gets admitted to a nearby hospital that is part of her health insurer’s network hospital list.
Here’s what happens next:
- Inform the TPA or Insurance Help Desk
Seema’s sister informs the Third Party Administrator (TPA) or the insurance help desk at the hospital and submits the insurance policy details and a pre-authorization form (usually available at the hospital’s TPA desk) - Verification & Approval
The TPA verifies Seema’s policy and confirms that the hospital is in the insurer’s network. Once approved, the hospital gets a cashless pre-authorization. - Treatment & Discharge Without Bills
The hospital then treats Seema and settles the bill directly with the insurance company. Seema doesn’t need to submit bills or make any payments upfront.
Moreover, there is no waiting period to get a benefit.
However, as per the terms and conditions, there might be a case that she still needs to claim reimbursement from her insurance company. This is a rare incident to happen in a network hospital. In such cases, Seema pays the hospital and then files for reimbursement. If certain expenses are not covered under her policy then she needs to pay for only those uncovered expenses which are clearly communicated at the time of buying the policy. The remaining will get reimbursed.
Read: Role of TPA in health insurance
Scenario 2 - Non-network hospital and reimbursement claim
Let’s break down what happens when you get treated at a non-network hospital.
Example: Mr.Tiwari had a sore throat and decided to consult a doctor. After further diagnosis, he needed to be hospitalized. Although he had an active health insurance plan, he got admitted to a non-network hospital, meaning, a hospital not tied up with his insurer.
What this means:
Even if Mr. Tiwari’s policy offers cashless benefits, he cannot avail of cashless hospitalization at a non-network hospital. That facility is available only at network hospitals.
Here’s what happens next:
- Pay First, Claim Later
Mr. Tiwari had to pay for the entire treatment cost out of pocket at the time of discharge. - Reimbursement Process
Post-treatment, he had to collect all hospital bills, prescriptions, and discharge summaries then Submit a reimbursement claim to the insurance company and Wait for the insurer to review the claim as per policy terms. - Reimbursement Outcome
Depending on his policy’s coverage and exclusions, the claim may be, Fully reimbursed, Partially reimbursed, Or rejected after carefully reviewing the terms and conditions of the policy.
One take away from these scenarios is that it is better to get admitted to a network hospital unless there is an unavoidable emergency.
Differences between network hospital & non-network hospital
When to visit a non-network hospital?
After explaining the differences, it is crystal clear that you should always visit network hospitals. Only at the time of unavoidable health emergencies, it is advisable to visit the hospital nearest your proximity. In such unavoidable circumstances, it is unwise to start searching for a network hospital and waste time traveling. Even a second can make a huge difference in the time of a health emergency.
What does it mean when a hospital is blacklisted?
A blacklisted hospital is one that has been removed from the insurer’s network list due to unethical practices such as overcharging, false claims billing, or poor service. If you get treated at a blacklisted hospital, you won’t be eligible for cashless claims, and in most cases, even reimbursement claims may be denied unless it’s an emergency and you provide valid documentation.
Claim processing, formalities, and waiting time in network hospitals and non-network hospitals
Understanding the claim settlement process is crucial when it comes to making informed decisions during medical emergencies. Here's how the claim processing, formalities, and waiting time vary between network and non-network hospitals.
Network Hospital Claim Process (Cashless)
When admitted to a network hospital, your claim process is Fast, Seamless, Cashless.
All you need to do is:
- Submit a pre-authorization form at the hospital insurance/TPA desk.
- The hospital forwards it to your insurer’s Third-Party Administrator (TPA).
- TPA verifies the claim as per your policy terms.
- Once approved, you receive an authorization letter.
- Your treatment expenses are directly settled between the hospital and the insurer.
And, this entire process is completely cashless with no waiting time.
Non-Network Hospital Claim Process (Reimbursement)
In the case of a non-network hospital, here’s what you’ll need to do:
- Pay the full treatment cost upfront.
- Collect all original documents: bills, prescriptions, reports, and discharge summary.
- Submit a reimbursement claim to your insurer post-discharge.
- The insurer reviews the claim thoroughly, including exclusions and policy conditions.
Here, the waiting period is 10-15 working days for verification. People face a lot of issues with their medical expenses not getting approved which means it has higher chances of not getting the approval. There is so much scrutiny around hospitalization claims at non-network hospitals not to forget all the hassle one goes through.
Network and non-network hospitals in group health insurance
Network and non-network hospitals work the same way in group health insurance as well. Here, employees can avail of cashless claims in network hospitals and reimbursement claims in non-network hospitals.
At Pazcare, we make it all the more simple to access network hospitals and get claims settled. Employees can use the Pazcare app to check the network hospitals of their insurer based on the Pincode or locality. We also help employees with claims during health emergencies by providing all the information they need in such crucial times. Our customer support team is available 24x7 and is just a call away.
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