In cashless facility, Insurer can reject the claim after discharge or denied to pay hospital?

In cashless facility for health insurance in India, it is possible for the insurance company to reject a claim after the patient has been discharged from the hospital or to deny payment to the hospital. This can occur if the insurance company finds that the medical treatment provided was not covered under the policy, if the claim was submitted with incomplete or inaccurate information, or if there was fraudulent activity involved.

Insurance companies typically have a process for reviewing and approving claims, which may involve the verification of medical records and other documentation. If the insurance company finds that the claim does not meet the policy criteria or that there is insufficient evidence to support the claim, they may reject the claim or deny payment to the hospital.

In such cases, the hospital may need to bear the cost of the medical treatment provided, and the patient may need to seek reimbursement from the insurance company or pay the expenses out of pocket. Hospitals may also need to have internal processes and controls in place to minimize the risk of claim rejection or payment denial.

It is important for hospitals and patients to be aware of the terms and conditions of the insurance policy and to ensure that all documentation and information related to the medical treatment is accurate and complete. In case of any dispute or disagreement with the insurance company, hospitals and patients may need to seek legal advice or approach regulatory authorities such as the Insurance Regulatory and Development Authority of India (IRDAI).