Lesson 3 of 3 · 8 min
Cashless, top-ups, and Ayushman Bharat
How a claim actually gets paid, how cover is extended cheaply with a top-up, and what the government scheme does and does not do for your family.
| Dimension | Cashless | Reimbursement |
|---|---|---|
| How it works | The insurer settles directly with a network hospital | You pay the hospital, then claim the money back with bills |
| Money out of pocket | Deposits and non-covered items only | The full bill, until the claim is settled |
| Paperwork | Pre-authorisation form at the hospital's insurance desk | Discharge summary, original bills and reports, claim form |
| Where it applies | Hospitals on the insurer's network list | Any registered hospital |
Clocks the regulator set in 2024
- Cashless approval
- 1 hour
- Discharge approval
- 3 hours
- Free look
- 30 days
- Portability window
- 45 days
An insurer has to decide on a cashless authorisation request within one hour.
Final authorisation at discharge within three hours, so patients are not stuck at the billing counter.
A new policy can be returned within 30 days of receiving it, with the premium refunded after small adjustments.
Apply to switch insurer at least 45 days before renewal — waiting periods already served travel with you.
Cover can be extended without buying a bigger base policy. A top-up pays only after a claim crosses a threshold called the deductible — which is why it costs so little. The catch is in how the threshold is counted, and that one word decides everything.
Top-up or super top-up: how the threshold counts
Which situation is the extra cover for?
Quick check
Base cover ₹5 lakh. A super top-up of ₹20 lakh sits above a ₹5 lakh threshold. Two separate claims of ₹3 lakh each land in one year. What does the super top-up pay?
Myth
“Ayushman Bharat covers every Indian, so nobody needs their own policy.”
Mostly false
PM-JAY gives ELIGIBLE families ₹5 lakh of hospitalisation cover per family per year, cashless at empanelled hospitals — a genuinely large public programme. But eligibility is based on deprivation criteria from official databases, plus all citizens aged 70 and above. Most salaried urban households are not eligible, and treatment is at empanelled hospitals only. Knowing whether your family qualifies takes two minutes on the PM-JAY site — worth checking rather than assuming either way.
Just for you
If someone at home were hospitalised tonight: which policy pays — an employer's, the family's own, or none? And does anyone besides you know where the policy document is?
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Check yourself
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Kabir asks
Base cover ₹5 lakh. A super top-up of ₹20 lakh sits above a ₹5 lakh threshold. Two separate ₹3 lakh claims land in one year. What does the super top-up pay?
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