What is a General Insurance company?
General Insurance Company offers Non-life portfolios like Motor Insurance, fire
insurance, Marine insurance and medical insurance. Insurance company is the one
that underwrites the policy and hence it is important that the policy holder educates
himself well about the policy when buying it.
What is a Third Party Administrator (TPA)?
Third Party administrator is a corporate body recognized by IRDA, appointed for
the administration of your medical insurance (Mediclaim) policy. TPA would therefore
be responsible for processing and settlement of claims. They are also responsible
for processing cashless request at network hospitals.
What is Mediclaim?
Mediclaim Insurance is a hospitalization benefit policy offered by general insurance
companies. This policy enables the policy holder to get the hospitalization expenses
reimbursed. Alternatively policy holder can also go for cashless facility in one
of the network hospitals.
What are Network Hospitals?
A hospital that has an agreement with the TPA/insurance company to extend cashless
facility to the Policy holder in the event of planned / emergency hospitalization.
What is Cashless facility?
This facility is extended by the insurance company/ TPA to their card holders. This
means the policy holder, if needs to be admitted for a surgery or in patient treatment,
approaches a network hospital. The network hospital would provide him a pre-authorization
request. Filled Pre-authorization form is then sent to the TPA/ insurance company.
Panel of doctors at the TPA/ Insurance company would send the approval/ denial letter
to the hospital.
What is Pre-authorization request?
This form is available with all the network hospitals. It has two sections. First
section is to be filled by the policy holder. This will have general information
like Name of the patient, Age, sex, Policy Number, Card number, etc.,Second part
is to be filled by the doctor. This will have medical information like, diagnosis,
probable duration of stay in the hospital, Approximate cost of the treatment, etc.,
What is Enhancement?
When the amount authorized exceeds the final bill amount, hospital would send an
enhancement request to the TPA/ Insurance company.
How does Cashless facility being extended?
We need to understand that the transaction is a cashless one but not free. Hospitals
have been instructed to extend cashless facility only on the receipt of authorization
letter from the TPA/ Insurance Company. After the hospitalization is authorized,
credit bills are raised and sent to the TPA / insurance companies for payment. Policy
holder enjoys benefit of not spending money from his pocket for his / her hospitalization.
What do we do in case of planned hospitalization?
In case of planned hospitalization, the probable date of admission is known to the
patient. The patient is advised to establish contact with the corporate help desk
of the hospital. Pre-authorization request to be sent to the TPA /Insurance company
at least 4 days prior to the date of admission. This minimizes last minute tensions
and makes the transaction hassle free. In case of emergency hospitalization, patient
is advised to contact the corporate help desk immediately. Our corporate help desk
will assist you in getting the approval. But remember almost 90% of the procedures
at our hospitals are day care procedures and therefore the patient is available
in the hospital for only very few hours. But the pre-authorization procedure takes
almost 4-5 business hours. This makes emergency hospitalizations little difficult.
However, when the cashless facility is not obtained policy holders can get their
medical expenses reimbursed by submitting all the documents.