Care Health Insurance has temporarily stopped servicing cashless claim settlements across all 12 Max hospitals across Delhi-NCR effective February 17, 2025. This includes 8 super-specialty hospitals, 2 multi-specialty centers, one hospital in Gurgaon, and one cancer care center in Lajpat Nagar, Delhi. As per a statement available on the health insurer’s website, “With immediate effect, we have ceased cashless claim services at all Max Hospitals in Delhi-NCR due to unsustainable demands from a customer’s perspective.”
Notably, only cashless claims settlements across Max hospitals in Delhi-NCR have been temporarily discontinued. Care Insurance policyholders will continue to get the facility of cashless claim settlements across other Max Hospitals across the country.
Also Read: LIC’s health insurance claim rejection on grounds of alcohol consumption upheld by SC, know why
So, if you happen to have a health insurance policy from Care Health and are planning to get treatment at Max Hospitals across Delhi NCR, you will not be able to avail yourself of a cashless settlement.
This simply means that Care Health, i.e., the insurance company in concern, will not be directly settling bills with Max Hospitals in Delhi-NCR until further notice.
Can I still avail of treatment at Max Hospitals across India if I have a health insurance policy from CARE?
Yes. Generally, claim settlements are of 2 types: cashless and reimbursement. Under a cashless settlement, your insurance company directly connects with the hospital where you’re getting treated, generally via a TPA (third-party administrator), and settles your bill. This saves you the hassle of paying bills from your own pockets. However, in cases of reimbursements, you are first required to pay the hospital bill yourself and then raise a claim with your company. Then, depending on your policy coverage, the insurer will reimburse or recompensate you.
However, if a customer still chooses to avail themselves of the cashless treatment at any Max Hospital in Delhi NCR, “Our team will promptly assist them upon claim intimation and ensure a smooth treatment process,” the insurer noted.
Detailing this, official sources close to Care Health noted that if customers still choose to get themselves treated in a Max Hospital, CARE Insurance will compensate them beforehand so that they can settle their bills with the hospital on their own.
As per IRDAI guidelines, to avail of cashless treatment for planned surgeries or hospitalizations, the policyholder must inform the insurance company at least 72 hours prior. As for emergency admission, it should be intimated to the insurer within 24 hours of hospitalization.
Moreover, you always have the option of getting it reimbursed from your health insurance provider. According to IRDAI’s 2024 master circular on policyholder protection, settlement of all claims (other than cashless) shall be settled within fifteen days from submission of the claim. However, unlike a cashless claim, where the entire claim is settled between the hospital and the insurer, there is a likelihood of the reimbursement amount being much less than the bill raised by the hospital, as the insurer might not pay the part of the bill that it is protesting against.
Why do insurers delist hospitals from their network?
According to Ms. Sarita Joshi, Product Head of Health and Life Insurance at Probus, differences in tariffs or pricing is the single biggest reason why insurers delist hospitals
“If the insurance company thinks that the treatment cost that should be payable for a particular treatment is significantly higher than what the hospital is charging, they tend to delist them from their list of network hospitals,” she added.
Official sources close to Care Health confirmed that a disagreement in treatment prices was also the main reason why Max Hospitals had been delisted from their network. However, they are currently in conversation with them to reinstate this partnership.
“In just the past year, we can recall 4 instances where leading insurance companies delisted the hospital from their network, largely due to treatment tariff differences. When we lock in a hospital for a network, we agree on prices for each course of treatment for different regions across the country for 2-3 years. However, if there are significant divergences in the treatment charges that are calculated and quoted by the insurer and hospital, the insurance company may decide to delist them temporarily,” official sources close to Care Health explained.
As per the insurer, continuing to give in into the potentially inflated tariffs quoted by hospitals every time would mean an upward revision of premiums for policyholders, which would not bode well for those having health insurance policies.
Max Hospital remained unavailable for comment on this matter.
Delisting a frequent, temporary process, not time-bound
This is not the first time an insurance company has delisted a hospital. If insurers and hospitals reach a pricing agreement, “If things work out between the insurer and the hospital, it can come back to the network panel again. There is no specific time for it. There is no time duration within which the hospital and insurer have to settle things. It purely depends on the agreement reached between both parties,” adds Joshi.
As opposed to delisting, blacklisting happens when insurers identify increased instances of fraudulent activities and claims from a hospital. Every insurer has a specific list of blacklisted hospitals available on their website.
Claims made for treatment in such hospitals are not entertained under any circumstances. The only exception to this condition is certain life-threatening cases or accidents, in which case the insurance company is liable to honor claims coming from such blacklisted hospitals.
