MEDI CLAIM COVERAGE AND ACCESS

Do all Health Insurance Policies offer cashless hospitalization facility ?

Today, most Health Insurance policies do offer cashless hospitalization facility and route your policy through a Third party Administrator (TPA). However you should be familiar with the terms-Network Hospital and Non-network Hospital.

Network Hospitals are those Hospitals that your TPA has an agreement with. In case of hospitalization, if you get admitted to a Network Hospital you will be eligible for cashless hospitalization, subject to the other terms and conditions mentioned in your policy being fulfilled. In case you are admitted to a Non-network Hospital, you will have to settle the bills directly to the hospital and then seek reimbursement through your TPA.

Does Cashless hospitalization mean I can just walk into a hospital and get admitted for treatment free of cost?

1. First, you need to be clear that there is no free treatment. It is just that, in the case of a cashless hospitalization, the insurance company will bear the cost of treatment either fully or partially on your behalf.
2. Cashless hospitalization is a facility provided by most health insurance policies and enables an insured customer to obtain admission and undergo the required treatment without a direct payment. The assigned TPA will mediate between the health care service provider (Hospital) and the insurance company and settle the bills on behalf of the insured customer.
3. However it is important to understand the role of a hospital in cashless hospitalization. The hospital is only a facilitator and has no authority to approve or disapprove any request for cashless hospitalization. Certain protocols laid down by the Insurance Regulatory and Development Authority (IRDA) with respect to cashless hospitalization will need to be adhered to strictly.

What procedures should I follow to avail the facility of cashless hospitalization at hospital?

Hospitalization happens under two circumstances - Planned and Emergency. Pre-authorization of the estimated hospital expense is a must to avail this facility.

• Planned Hospitalization

In the case of a planned admission, you would have first consulted a doctor who in turn would have advised you on the probable date of hospitalization. In such a case, you must have applied for an approval of the estimated hospital expenses directly with your TPA prior to the date of hospitalization. In case you have not applied- for a pre-authorization sufficiently in advance or if the doctor treating you advises you to get hospitalize immediately after the consultation, the Insurance desk of the hospital will assist you through the pre-authorization procedure.

However, you will need to bear in mind that the Insurance desk is only a facilitator and can in no way influence the decision on the approval. The approval or rejection of cashless facilities is the sole discretion of the TPA / Insurance Company.

The Pre-authorization procedure is detailed below:

Step 1 : Establish contact with the Insurance Desk at the hospital.

Step 2: At the Insurance Desk, you need to present the health Insurance card issued to you by your Insurance Company / TPA.

Step 3: Collect the Pre-authorization form pertaining to your Insurance Company / TPA.

Step 4: Your Pre-authorization will have two section -

• General details on the health Insurance policy - to be filled in by you. ( The Insurance desk will assist you in case you have any difficulty)
• Pertains to the treatment recommended for you-needs to be filled in and duly signed by the Doctor who is treating you (do not attempt to fill this section), contact your doctor or Insurance desk.

Step 5: Return the completed form to the Insurance desk. The personnel at the desk will verify the form for its completeness and let you know in case of any discrepancy.

Step 6: Once the form is complete in all respects, the Insurance desk will sent the Pre-authorization form through TPA or Insurance web-portal or email to the office of your Insurance company / TPA.

Step 7: The Insurance desk will revert to you on the approval status.

Emergency Hospitalization

In case of emergency hospitalization, the Insurance desk will take up your case on a fast track basis with your TPA and is likely to receive approvals within 4 - 6 hours during any working day.

For cashless treatment it is mandatory for the hospital to have an approval from your TPA. Incase of delay in receiving the approval or when you cannot wait for receiving the approval owing to medical urgency you can undertake the treatment by paying the necessary cash deposit.

If you receive approval from your TPA after paying the cash deposit, you are entitled for refund of the cash deposit.

What do I do, If I do not get approval on my cost of treatment till the time of discharge at the hospital ?

Cashless hospitalization is linked to the approval of the estimated expenditure on your proposed treatment. In case you do not get your approval you will need to bear the entire expenditure incurred on the treatment. Therefore it is always prudent to get the approval and then get yourself admitted. You could explain the benefits of getting the approval before the date of your admission to your treating doctor as well when he recommends an immediate admission.

The hospital will not entertain any request for a refund of the amount paid by the patient / attendees if the approval comes after the process for your discharge has commenced.

Under what circumstances will the request for cashless hospitalization not be entertained?

Normally your request for approval might be rejected when:

1. Information contained in the pre-authorization form is insufficient for the TPA / Insurance Company to arrive at a decision and further information is not available for various reasons. However the chances of rejection under this criterion are rare since the Insurance desk at the hospital is experienced in complying with Pre-authorization formalities and will advise you suitably.
2. The ailment for which hospitalization is being sought by you is not covered under your insurance policy for reasons like pre-existing ailment, specific exclusions (Accident admission under the influence of alcohol).
3. You have exhausted your eligible Medical Insurance cover for the year.

What do I do if the actual medical expenses overshoot the pre-approved amount?

In case your hospitalization expenses exceed the pre-approved amount, you can approach the Insurance Desk to apply for an enhancement of the Pre-approved amount.

The Insurance Desk will apply for an enhancement on your behalf with TPA / Insurance Company and provide the necessary document. In case you have not exhausted your medical insurance limit, it is most likely that your TPA will approve the application for the enhancement-either for the requested enhanced amount or up to your insured limit after deducting the value already utilized by you during the year - whichever is less.

If the TPA / Insurance Company turns down the request for enhancement you will need to pay the amount incurred in excess of your approved amount directly to the hospital before the discharge.

Does cashless hospitalization cover all medical expenses?

For complete details on the medical expenses that are covered, and those that are not covered, you need to go through your health Insurance policy. It will be mentioned under " Non Payable Items".