Network vs Non-Network Hospitals: A Guide for Employees

Frequently asked questions

If you are comparing network hospitals and non network hospitals, the distinction is straightforward: a network hospital is on your insurer’s or TPA’s (third-party administrator’s) listed cashless-provider network, while a non-network hospital is not. At a network hospital, you can request cashless treatment. At a non-network hospital, reimbursement is commonly the route unless your insurer confirms another arrangement. In both cases, payment depends on pre-authorisation and your employer group policy’s terms, coverage limits and exclusions. IRDAI’s health-insurance guidance explains that cashless payments are made to empanelled hospitals only to the extent approved, and that insurers’ websites should show hospital lists and claim procedures.

For employees, the hospital choice can affect how much money they need to arrange upfront and which documents they must keep. For HR teams, the practical role is to direct people to the right insurer, TPA and support contacts without promising a claim decision. This guide supports both groups alongside your employer group health insurance.

What is the difference between network hospitals and non-network hospitals?

A network hospital is a hospital or healthcare provider empanelled by the insurer, a TPA, or both to provide cashless services. A non-network hospital is a hospital or provider outside that insurer’s network. The network is insurer- and policy-specific. The same hospital may offer cashless treatment under one group policy but not another. IRDAI’s guidance says insurers should publish the hospitals and healthcare providers with which they have cashless tie-ups, along with the cashless and reimbursement procedures.

The label does not determine whether treatment is medically needed or whether every part of a bill is payable. It mainly describes the claims-servicing route. Your Certificate of Insurance, policy schedule, customer information documents and pre-authorisation decision remain relevant. Insurance cover is always subject to the terms of the group policy.

The direct answer: when cashless treatment may be available

For cashless treatment at a network hospital, show your e-card or policy details at the hospital’s insurance desk and ask it to send a cashless pre-authorisation request to the insurer or TPA. If the request is approved, the insurer pays the approved amount directly to the hospital. Cashless is a settlement method, not a blanket confirmation that the entire bill is covered. IRDAI defines cashless facility as direct payment to the empanelled provider to the extent of the approved cashless amount and in line with policy terms.

Do not assume cashless access because a hospital appeared in an old directory, a colleague used it earlier or it is well known locally. To find network hospitals for health insurance, use the current insurer or TPA directory linked to your policy. Then call the hospital’s insurance desk to confirm that it can raise a request under your employer’s policy.

For planned treatment, start this check early. IRDAI states that insurers should decide a cashless pre-authorisation request immediately and no later than one hour after receiving it; it also sets a three-hour timeline for final cashless authorisation after the hospital sends a discharge-authorisation request. These service timelines do not remove the need for the hospital, insurer or TPA to assess the request against policy terms. See IRDAI’s published health-insurance turnaround times.

How reimbursement at a non-network hospital generally works

A non network hospital reimbursement claim generally starts with the employee or family paying the hospital and retaining the complete treatment and payment record. The employee then submits a reimbursement claim to the insurer or TPA according to the policy’s process. IRDAI requires insurers to make reimbursement steps available and to indicate that policyholders using providers outside the listed cashless hospitals may need to file a reimbursement claim. IRDAI’s health-insurance guidance also lists a 15-day turnaround time for settlement of claims other than cashless claims, subject to the applicable requirements.

Keep originals or clear copies of the documents requested by the insurer or TPA. These commonly include the claim form, hospital bills, receipts, discharge summary, investigation reports, prescriptions and payment proof. Use the document checklist supplied for your specific group policy. Do not discard papers simply because a hospital has uploaded some records electronically.

A network hospital can also become a reimbursement case if cashless pre-authorisation is not obtained, is unavailable for a particular admission, or is not approved for the requested amount. Employees should therefore distinguish between the hospital’s network status and the cashless approval for a specific treatment episode.

For a wider overview of documents, communication and follow-up, see our guide to the group health insurance claim process.

What employees should check before a planned hospital visit

For planned care, take these steps before admission wherever possible:

• Check your active cover. Keep your e-card, employee ID, insurer name, TPA name, policy or certificate number and helpline details ready.
• Check the current network. Use the insurer or TPA directory rather than a saved screenshot. Insurers are expected to make available their cashless hospital lists and claim processes. IRDAI’s guidance on information available through insurer websites covers both hospital lists and reimbursement steps.
• Ask the hospital to raise pre-authorisation. Share the correct employee and patient details, and ask what information or records are needed to process the request.
• Read the policy-specific limits. Check room-rent rules, co-payments, deductibles, sub-limits, exclusions, waiting periods and eligibility for the particular treatment. These can affect the employee’s contribution even when a cashless request is approved.
• Ask for clarity on likely out-of-pocket costs. The hospital may identify items that are not part of the insurer’s approved amount. Get this in writing where possible.
• Save every document and reference number. This helps if the final bill, cashless authorisation or discharge process needs clarification.

Employees who need help locating contacts or understanding benefit access can use employee benefits and support. For common questions about enrolment, cover and claims, share the group health insurance FAQs.

What to do in an emergency when the hospital is not in the network

In an emergency, prioritise getting to an appropriate hospital. Inform the insurer, TPA or employer support contact as soon as practicable. Ask the hospital’s insurance desk whether it can send a cashless request, and ask the insurer or TPA whether a cashless arrangement can be considered. Do not assume cashless availability at a non-network hospital. Seek confirmation for that admission.

If you need to pay, preserve all bills, receipts, discharge records, diagnostic reports, prescriptions and payment evidence from the start. Notify the insurer or TPA through the channel and timeline stated in your group policy. The policy documents, not a general article, HR message or hospital verbal assurance, determine eligibility, documentation and the amount, if any, payable.

IRDAI states that insurers should make claim procedures and hospital information accessible on their websites. Its earlier circular also required insurers to ensure cashless facility at empanelled network providers where policyholders had been notified of that facility, in accordance with the policy contract and provider agreement. Read the IRDAI circular on provision of cashless facility.

How HR teams can help without making claim promises

HR can reduce confusion without acting as the claim decision-maker. A useful employee-facing process includes:

• sharing the insurer, TPA, e-card and escalation contacts during onboarding and renewal;
• keeping a simple link or instructions for the group health insurance network hospital list;
• reminding employees to verify network status and pre-authorisation before planned admissions;
• helping employees identify the correct claim route: cashless request or reimbursement submission;
• directing employees to the insurer, TPA or Healthysure support team for case-specific status updates; and
• recording recurring employee questions so the benefits guide can be improved.

Avoid statements such as “your claim will be approved” or “the insurer will pay the full bill.” A better HR response is: “We can help you reach the right claims contact, understand the process and collect the requested information; the insurer or TPA will assess the claim under the policy terms.” This avoids false certainty while still offering practical support.

FAQs: Can a hospital be removed from an insurer’s network?

Can a hospital be removed from an insurer’s network?

Yes. Network arrangements can change, so employees should check the live insurer or TPA directory before a planned admission. The insurer’s published hospital list and the hospital insurance desk are the best first checks for current status. IRDAI expects insurers to provide lists of hospitals and healthcare providers with cashless tie-ups on their websites. See IRDAI’s information-access guidance.

Does cashless treatment mean I will not pay anything at discharge?

No. Cashless means the insurer pays the approved amount directly to the empanelled hospital. You may still have to pay non-covered expenses, amounts above applicable limits, co-payments, deductibles or other charges that fall outside the approved claim. IRDAI’s definition of cashless facility makes clear that direct payment is only to the extent of cashless approval and subject to policy terms.

Can I use a non-network hospital if it is closer or preferred by my doctor?

You can choose the hospital that is appropriate for your situation, but the claim route may change. If it is not in the insurer’s listed network, confirm whether cashless can be arranged. Otherwise, be prepared for a reimbursement claim and retain all required records. IRDAI’s guidance says insurers should show both cashless procedures and reimbursement steps, including the need for reimbursement when a provider is not listed.

Who should employees contact first: HR, the hospital or the insurer?

For admission-related cashless questions, start with the hospital insurance desk and the insurer or TPA helpline shown on the e-card or policy documents. HR can help employees find the right contacts and understand the company’s support route, but should not commit to a claim outcome.

When reviewing your group health cover, ask for a clear employee-facing hospital-network and claims-support process. Get a group health quote for your SME.