When there is an illness of your near and dear one and you would like to avail the “CASHLESS” facility of Mediclaim insurance , here is how you go about.
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Check that the Insurance policy is a Valid One
Please check the start and end dates of the Mediclaim policy . The hospital admission should be in the policy period. Even if the hospital admission is in the policy period and the discharge is in the next policy period, the Insured will be eligible for cashless service.
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Please keep your Insurance TPA ID card ready
You have to deal with your Third Party Agent (TPA). The TPA will ask for your policy number and TPA ID number which is mentioned in their card. It also carries the contact numbers of the TPA.
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Talk to your Doctor to select the Hospital.
Cashless service is available only in Network hospitals, which have an agreement with the TPA/Insurance Company. So talk with your Doctor about which Hospital to get admitted for best cashless service.
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Cashless service for the 4 PSU Insurance Companies is now only in PPN Hospital?
The four PSU Insurance Companies ( New India Assurance , National Insurance Company Ltd, Oriental Insurance Company Ltd and United India Insurance Company Ltd ) continue to insist on providing Cashless service only in a small number of Hospitals called the “PPN” hospitals . The PPN Hospitals are supposed provide an agreed package price for certain procedures. This is a very opaque process which has been disallowed by a number of consumer court and ombudsman rulings . Even though the PPN list has no sanction from Consumer Courts and Ombudsman rulings, the PSU Insurance Companies from 1st July appears to be offering cashless facility only in their PPN enlisted hospitals. Talk to your Doctor to find a PPN Hospital, in case you have a policy from the one of the PSU Insurance Companies.
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Fill in the form for preauthorisation of cashless admission
The IRDA has a standardised preauthorisation form which sould be valid for all cases as per IRDA regulations. However, sometimes the TPA insists on their own form which might just have their logo and column for aadhar and pan card. Such forms are available for download from the TPA website.
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Enclose Copies of Aadhar Card and PAN card
Please enclose self attested copies of Aadhar and PAN card . Some times you might be asked to provide Aadhar and PAN card of the owner of the policy too. Eg the father is the owner of a family floater policy and the insured son is getting admitted under cashless system. The TPA might ask for Aadhar & PAN of both the son and the father.
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Please attach the Doctors prescription where he has advised admission
The TPA would like to know the diagnosis, the planned treatment and the duration of the illness. Please ensure that it is included and please ensure that it is not in the “exclusion list” in your Insurance Policy.
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Please attach Copy of any investigation in support of your diagnosis
If you have been diagnosed with a gall bladder stone and have been advised a gall bladder surger, the TPA might ask for the USG report in support of this diagnosis
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Please collect the Hospital’s seal in it.
The form needs to have the signature of the Insured patient, the treating doctor with his registration number and the Hospital seal.
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Send in the form through the Hospitals
Usually the Hospital sends in the form and its attachments to the TPA. Please ensure that it has been sent in time i.e. Few days before planned hospitalisation. For emmergency medical condition , the form is sent by the hospital after admission of the patient.
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Find out about the Approval letter
The TPA sends an approval letter to the Hospital through email. Please find out from the Hospital about the sanctioned amount. It is not uncommon for the TPA to sanction a lesser amount. The letter might have conditions of “co-pay” ie where the Insured has to pay a certain amount of the Hospital cost. The “ co-pay” clause is mentioned in the Policy. If you have a clause of 20 % co – pay and your Hospital bill is Rs 64 000 then you will have to pay Rs 12 800 and the rest will be paid by the Insurance Company.
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In case there is a query, work with your Hospital to answer it.
Sometimes the TPA sends in a query eg please give reasoning/ test reports of the diagnosis. The TPA might ask for duration of the disease to make sure it is not in the “exclusion list” of your Insurance policy.
You can find out about this by going into the logging in to the ” claims” page of your TPA.
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Ask for enhancement if the full amount of Hospitalisation expense has not been sanctioned.
It is quite common for the TPA to sanction less amount initially and then sanction the rest after completion of treatment and before discharge. This is called asking for “enhancement”. The enhancement request is sent in through the Hospital. You might have to follow up with the Hospital Insurence desk and with the TPA ( through phone ) to hasten any such process.
You can find out aboutthe status of your enhancement by going into the logging in to the ” claims” page of your TPA.
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Pay the outstanding amount of the Hospital bill.
The outstanding amount of the Hospital bill which is not covered by the TPAs letter needs to be paid. There are certain “exclusion items” eg sterilized gloves, toothpaste, toothbrush etc which the TPA does not pay you will have to pay at discharge.
Many times the TPA arbitrarily disallows part of hospital bill. Please pay it at discharge and collect proper receipts to claim back any such arbitrary deductions .
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Claim the Hospitalisation costs not allowed by the TPA.
The TPAs unfairly discourage you to claim such amount. If you feel that there have been unfair deductions from Hospital bill in your “cashless “ bill then please go ahead and claim it. Often payment of this part of the claim is held up till you lodge a complaint with the Branch Office of your Insurance Company or the Ombudsman.
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Claim the reimbursement of prehospitalisation costs.
You are eligible to claim the expenses incurred in the prehospitalisation period of one month. The exact duration is mentioned in your policy .The claim procedure is same as in case of reimbursement.
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Claim the reimbursement of post hospitalisation costs.
The expenses incurred in the 60 – 120 days following hospitalisation is usually elligible for reimbursement. The exact duration is mentioned in your policy .The procedure is same as in other reimbursement. It needs to be for the same disease condition.
NO MATTER HOW MUCH YOU ARE COVERED BY YOUR HEALTH INSURASNCE (MEDICLAIM ) , ALWAYS HOPE THAT YOU WILL NEVER HAVE TO CLAIM IT !!!