Difference Between Network Hospitals and Non-network Hospitals

If you have read through your health insurance plan document A-Z, we bet you’ve come across the huge list of network hospitals of your insurer. Now, what does the term ‘network hospital’ mean? How is it different from a non-network hospital?

All health insurance companies collaborate with a list of hospitals to offer their policyholders certain benefits on being admitted at those hospitals. These hospitals are known as ‘network hospitals’. On the other hand, hospitals that are not a part of the network of an insurance company are termed ‘non-network hospitals’.

Let’s find out the difference in benefits through some sample situations.

Situation 1

Mr. Sharma had opted for cashless insurance on his health insurance plan. This would give him the benefit of availing cashless services on getting admitted at any network hospital that his insurance company has a tie-up with. When he got admitted to a network hospital for medical treatment, all he had to do was flash his cashless card before getting hospitalized to become eligible for the cashless benefits. Hence, he could access the required medical treatment without burdening his pocket. How wonderful was that!

After he submitted the necessary documents as proof on being released from the hospital, his Third Party Administrator (TPA) coordinated with his insurer to get the entire medical expense reimbursed directly to the network hospitals. These documents included expenses incurred for diagnostic tests, doctors’ consultation fees, and charges for other medical treatments that he had undergone at the network hospital. His family members had maintained all the receipts and bills carefully and made sure that they submit all of them to the TPA to raise the claim on the entire expense incurred. Mr. Sharma had been very particular with timely payment of his premiums and, therefore, he had no hassles in availing the cashless benefits against his health insurance plan.

Situation 2

Mrs. Pal has a health insurance plan and decides to get admitted to a network hospital for the treatment of an illness that is covered by her policy. However, she had decided against opting for cashless benefits while purchasing her policy. Therefore, unlike in the case of Mr. Sharma, Mrs. Pal had to cough up a certain amount at the time of her hospitalization, without which she would not have been allowed to be admitted at the network hospital. When she was discharged from the hospital, she had to pay for the entire expenses incurred for her medical care and treatment at the hospital. She then raised a claim with her insurer and submitted the receipts and invoices as proofs of her medical expenses. The full medical expenditure was reimbursed to her account after the approval of her claim by the insurance company.

Situation 3

Next, let’s have a look at how the scenario pans when an individual gets admitted at a non-network hospital. Mr. Karthik had to be hospitalized at a non-network hospital on an emergency basis. Therefore, he would not be eligible for cashless hospitalization as the benefit is applicable at network hospitals only. When he was discharged from the hospital, he had to clear the entire expense incurred for his treatment from his pocket. He then made a claim, submitting all the required documents. When his claim was approved, the entire cost was reimbursed to him by the insurance company.

However, getting hospitalized at a non-network hospital exposes the insured to the risk of rejection of his claim in case the insurer finds the medical charges to be comparatively on the higher side than the standard costs. There are also situations where the insurance company may approve a claim partially and reimburse only the expenses that are within the standard market range. Apparently, he hadn’t been able to utilize all the benefits of his health insurance plan by getting admitted at a non-network hospital.

So, who’s the winner?

A network hospital or non-network hospital – which one should you opt for?

From the above read, it is quite evident that the policyholder of a health insurance plan should opt for a network hospital, unless the situation demands otherwise. An accident or unforeseen emergency certainly calls for immediate hospitalization. And in case of an absence of a network hospital at arm’s length, what would be the only solution? The answer is apparent.