All health insurance companys offer cashless hospitalization facility to policy holders.This facility is actually provided through a Third Party administrator(TPA). However as a policy holder you should be familiar with the terms of policies and method of availing cashless benefits.
Network hospitals are those hospitals that your TPA has an agreement with.In case of hospitalization,if you get admitted to the network hospital,you will be eligible for cashless hospitalisation,subject to other terms and conditions as in your policy.In case you admitted to a Non-network hospital,you have to settle the bills to hospital first and then seek re-imbrusement through your TPA.
Furthur,we should understand that cashless hospitalization does not mean a free treatment.It is facility provided by your health insurance company that enables an insured customer to obtain admission and undergo the required treatment without a direct payment.The assigned TPA will mediate between hospital and insurance company and settle the bills on behalf of insured customer.
It is also important to understand the role of hospital in cashless process.Hospital is only facilitator and has no authority to approve or disapprove any request for cashless hospitalization.
Hospitalization happens under two circumstances:
1.Planned Hospitalization.
2.Emergency Hospitalization.
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Planned Hospitalization:
You have diagnosed before and advised a surgery or procedure.You have consulted with doctors of that particular hospital and he has advised you a hospitalization.
In case of planned hospitalization,patient should approach mediclaim department of hospital in advance (at least 3-4 days) to fill your preauthorization form.Certain TPAs have made it mandatory to have prior approval for all such planned cases.Even if doctors advise you immediate hospitalization,then also approach immediately to mediclaim department.
Cashless hospitalization is linked to the approval of the estimated expenditure on proposed treatment.In case you did not get approval, you need to bare the entire amount of expenditure incurred on the treatment.Therefore its always better to get the approval and then get admitted for treatment.
To fill preauthorization form contact the liasioning officer of mediclaim department with:
1.Original mediclaim policy
2.PhotoId card issued by TPA
3.Photoidentity card like Pan card, driving license etc.
4.Admission note given by consulting doctor.
5.All investigation reports.
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Emergency Hospitalization:
In case of emergency hospitalization,one should contact mediclaim department immediately.For cashless facility,it is mandatory for the hospital to have an approval from your TPA.Hospital can ask you to pay (refundable) deposit till getting the approval.It doesn’t mean that approval is guaranteed .If approval is denied or partially approved due to any reason,you need to pay the amount incurred in excess of your approved amount directly to the hospital before discharge.
Cashless mediclaim do not cover all the expenses.Policy holders should find out from their insurance company,TPA,insurance advisor the list of diseases and other conditions which are not covered under your policy before applying for cashless hospitalization facility.
Click Here to know what may not be covered in your mediclaim Policy:
Thanks for the informative post.
I have insurance coverage for my dependent by virtue of my employment in an IT firm. I am a novice in availing insurance for medical expenses but looking to avail this time in the cashless mode.
How can one know who the TPA is? Will this information be available at the hospital’s mediclaim department for the particular insurance provider for the particular city for the particular hospital.
Hi Sriram,
In case of mediclaim cover provided by the company,you will get better information like TPAs, major exclusions from HR department of your firm.One need to check that which type of service[Deluxe,private,semi-private] is covered from cover provided by the company.