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One of the best features of any health insurance policy is the “Cashless service” offered by the insurance company. In a cashless claim arrangement, the insurance company directly pays to the hospital and the policyholder does not have to pay for the treatment or hospitalisation from his/her pocket. But there can be times when this blissful cashless service can become really painful and annoying. There have been many instances where the policyholder or his family members spend a lot of their time and energy in chasing the Insurer, following up with their Third-party administrator (TPA) and the Accounts department of the hospital.
Hospitalisation and treatment can be broadly classified in two ways – 1) Unplanned Hospitalisation and 2) Planned Hospitalisation. Unplanned situation arises in case of an accident, emergency or any situation requiring immediate hospitalisation without prior planning. Planned situation, as the name suggests, means that you are aware of the illness or injury and prepared for hospitalisation at a sooner or later date. This article is mainly aimed at cases involving planned hospitalisation. Getting a Cashless claim settlement on your health insurance policy can be easy provided you know a few things before hand.
Some of the useful tips are listed below -
1. Cashless Hospital Network List – Health insurance companies tie up with TPA’s who actually process your claims and handle the entire paperwork. These TPAs have a list of network hospitals and they will provide cashless facility only if you go to one of these hospitals for treatment. So, it is a good practice to check this network hospital list before deciding on the hospital. Every policy kit comes with a list of all network hospitals in the country.
2. Know what is Covered and what are the Exclusions - An insurance company always gives the details of the expenses they will cover such as Inpatient Treatments, listed Day Care Procedures, doctor’s fees, etc.
· Inpatient Treatment - means any treatment which requires minimum 24 hour hospitalisation. So in simple words, if your treatment does not require you to be admitted to the hospital for a minimum of 24 hours, then the same is not covered
· Day Care Procedure - There are certain treatments which do not require 24 hour hospitalisation due to medical advancement, nature of treatment, etc such as chemotherapy, radiotherapy, cataract, removal of tonsils etc. These are listed in your policy document and differ from one policy to another. Remember – your insurer will only cover procedures listed in the policy.
3. Intimate your TPA (as an extra precaution, intimate your Health Insurer as well)
Your health insurance policy document mentions that in case of emergency hospitalisation, you must contact your TPA as soon as possible or within 24 hours of admission. The sooner you contact your TPA, the better are the chances that they will make a cashless settlement to your hospital. In case of a planned hospitalisation, it is best to contact your TPA at least a week or 5 days before getting admitted.
4. Complete all the paperwork
As soon as the policyholder is admitted in the hospital, one of the family members should go to the TPA desk or insurance desk at the hospital and fill up all the necessary forms. Send a copy of this duly filled form via Fax and Email along with the Doctor’s diagnosis and any medical reports you may have like XRay, CT scan, Blood report etc to the TPA.
Do not delay or waste any time in doing this process no matter how frustrating it may be. The TPA desk at the hospital may have hundreds of claim forms lying with them and may not always be prompt and quick. Ultimately, it is you who needs a cashless settlement, not them. As soon as the fax and email is sent out to your TPA, call and confirm the receipt. Check if any further documents are required and do it, call them again and confirm.
5. Verification process and payment release
The TPA will check your claim form, other documents and nature of treatment and sends you an initial approval of some amount. For instance, if the estimated cost of the treatment is Rs 1.5 lakhs, the TPA may send an initial approval of Rs 1 lakh. This does not mean that they will not pay the full cost of treatment. The balance amount will be paid at the time of discharge when the hospital gives the final bill to the TPA. After verifying all the paperwork, the TPA gives the final approval and pays the final settlement amount to the hospital.
Many of us feel that insurance companies keep too many restrictions and processes so that they do have to pay the money in advance, but this is not the case. Insurance companies are constantly working on innovative ways to improve their customer offering, claim process and customer service. It is our duty to be prepared with the required paperwork and formalities at such times to make it easier for them to process our insurance claim.