No Cashless Claims for CARE Health Policyholders at Max Hospitals in Delhi-NCR

The decision affects eight super-specialty hospitals, two multi-specialty centers, one Gurgaon hospital, and a Lajpat Nagar cancer care center.

CARE Health Insurance has temporarily discontinued cashless claim settlements at all 12 Max Hospitals in Delhi-NCR, effective February 17, 2025. 

The insurer cited "unsustainable demands from a customer’s perspective" as the primary reason for this move. 

The decision affects eight super-specialty hospitals, two multi-specialty centers, one Gurgaon hospital, and a Lajpat Nagar cancer care center.

While policyholders in Delhi-NCR will no longer have access to cashless services at Max Hospitals, CARE Health has confirmed that the facility remains available at other Max Hospitals across India.

Policyholders Can Still Seek Reimbursement

Patients with CARE Health policies can still receive treatment at Max Hospitals but must opt for reimbursement-based claim settlements. This means that they must pay the hospital bills upfront and then file a claim with the insurer.

According to official sources from CARE Health, "If customers still choose to get treated at Max Hospitals in Delhi-NCR, our team will assist them upon claim intimation and ensure a smooth treatment process." The insurer has also assured that in certain cases, they may compensate policyholders in advance to help them manage hospital expenses.

According to the Insurance Regulatory and Development Authority of India (IRDAI) guidelines, insurers must be informed at least 72 hours in advance of planned surgeries or hospitalizations. In emergencies, the insurer must be notified within 24 hours. CARE Health has confirmed that reimbursement claims will be processed within 15 days of submission, as per IRDAI’s 2024 master circular on policyholder protection.

Dispute Over Treatment Costs Led to Delisting

Industry experts suggest that the primary reason for delisting hospitals from an insurer’s network is pricing disagreements.

Sarita Joshi, Product Head of Health and Life Insurance at Probus, explained, “If an insurer finds that a hospital’s treatment costs are significantly higher than the agreed-upon tariffs, they may delist the hospital from their network.”

Official sources from CARE Health confirmed that a dispute over treatment tariffs was the key reason behind the delisting. However, discussions between CARE Health and Max Hospitals are ongoing to resolve the issue.

"In just the past year, there have been at least four instances where insurers delisted hospitals due to treatment cost differences. When we onboard a hospital into our network, we negotiate prices for various treatments for a period of two to three years. If the hospital’s charges deviate significantly from what the insurer has calculated, a temporary delisting may occur," said a source from CARE Health.

The insurer also noted that accommodating increasing hospital tariffs without negotiation could lead to higher insurance premiums, impacting policyholders. Max Hospital has not issued any statement regarding this development.

Delisting Not Permanent, Negotiations Underway

Insurance industry experts clarified that hospital delisting is a common practice and does not necessarily indicate a permanent severance.

"If an insurer and hospital reach an agreement on pricing, the hospital can be reinstated in the network panel. There is no fixed timeline for this process—it depends entirely on the negotiations between both parties," Joshi added.

Unlike delisting, blacklisting is a more severe action taken when an insurer detects fraudulent activities from a hospital. Claims from blacklisted hospitals are generally not honored unless they involve life-threatening emergencies or accidents.

CARE Health has assured that while cashless claims are currently unavailable at Max Hospitals in Delhi-NCR, discussions are ongoing, and the situation may change based on future agreements.