Your easy guide to avail cashless Hospitalization
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 re-imbursement through your TPA.
Does cashless hospitalization mean I can just walk into a hospital and get admitted for treatment free of cost?
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.
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 healthcare service providers (Hospital) and the Insurance Company and settle the bills on behalf of the insured customer.
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 Apex Hospitals?
Hospitalization happen fewer than two circumstances – Planned and Emergency. Pre-authorization approval of the estimated hospital expense is a must to avail this facility.
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 at least 2-3 days 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 hospitalized immediately after the consultation, our Insurance Cell will assist you through the pre-authorization procedure.
However, you will need to bear in mind that the Insurance Cell is only a facilitator and can in no way influence the decision on the approval. The approval can be turned down.
The pre-authorization procedure is detailed below:
In case of emergency hospitalization, the Insurance Cell will take up your case on a fast track basis with your TPA and is likely to receive approvals within 3 hours during any working day.
For cashless treatment it is mandatory for the hospital to have an approval from your TPA. In case 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.
At Apex Hospital the Insurance Cell will not entertain any request for a refund of the amount paid 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:
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 Cell to apply for an enhancement of the pre-approved amount.
The Insurance Cell will apply for an enhancement on your behalf with the TPA and provide the necessary documentation. 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 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. However, in general, the expenses listed below are not reimbursable under cashless hospitalization.
Note: These need to be settled by you directly to the hospital at the time of discharge.
In case of cashless hospitalization, what are the documents the hospital requires from me at the time of discharge?
All the original documents including bills, lab reports, discharge summary and claim form. All the original documents duly signed by you need to be submitted to the hospital.
Who is the TPA’s with whom Apex Hospital has a tie-up?
Apex Hospital has a tie-up with several TPA’s. (Current list is given below). However this is dynamic and will change from time to time. Kindly contact the Insurance Cell for an updated list.
A special benefit extended by an insurer or by the assigned TPA for availing medical treatment as an inpatient without the necessity to pay the treatment costs up front to the hospital. Under this procedure the payment due to the hospital will be met out either by the insurer or by the assigned TPA. After the discharge from the hospital the bills pertaining to medical expenses incurred at the hospital, are sent to the Insurer /TPA, (subject to insurance policy and conditions) for reimbursement by the hospital. The hospital can claim in accordance to the preauthorized limit and additional cost as envisaged by the enhancement. In any case the upper limit of this facility cannot exceed the sum insured under the contract of insurance.
Repudiation of a Pre Authorisation request /Admission liability/cashless facility and or settlement of a claim under the insurance contract.
Any difference between the amount claimed and admissible amount and also any violation of terms & conditions of the insurance policy or agreement.
Medical treatment for period exceeding 3 days for such illness/diseases/injury which in the normal course would require care and treatment at a hospital but is actually taken whilst confined at home under certain circumstances (where the patient cannot be moved to the hospital or due to lack of accommodation – as per the definition of insurance policy).
Situation when insurer seeks to increase the limit of the authorized claim amount resulting from extension of hospitalization.
The items that are specifically and expressly removed from the scope of the insurance contract and hence are not payable.
Medical treatment after getting admitted in a hospital.
The maximum limit up to which the insured can seek medical treatment under that mediclaim policy.
Individual who by paying a premium secures himself to receive medical treatment up to a fixed sum of money in the event of injury, loss or damage to his body.
A corporate body licensed by IRDA for underwriting various insurable risks against any or all insurable perils with an assurance to make good the loss in an unforeseen eventuality.
Insurance Regulatory & Development Authority, a body constituted under the Ministry of Finance to deal with licensing, regulating and monitoring all activities relating to the insurers, brokers, agents, corporate agents and the TPA’s.
Restrictions in the operative clause of the insurance contract to the limit of benefits use etc.
A card issued by your TPA with a primary purpose of identification. This contains the policy number, name and validity period. Many of the TPA’s prefer to place insured’s photograph & signature to improve its authenticity. Though it is being popularized as a cashless card, it serves only as a means to avail cashless benefit subject to the terms & conditions of the policy.
An insurance policy that covers hospitalisation expenses incurred during an inpatient hospitalization. Please check terms and conditions of the policy to understand the nature and the scope of risk covered.
Medico Legal Case
A situation arising out of treatment at the hospital for any bodily injuries sustained in an accident or an attempt of suicide, which needs to be intimated to the police and other concerned authorities for any investigation and procedures. (Burns, Suicide, RTA, Assault)
An hospital which has entered into an agreement / MOU with an insurer or a TPA to request preauthorization, extend cashless facility and accept payment at a later date on submission of bill complying to the policy requirements. Those hospitals that do not have a prior agreement for cashless hospitalization with your insurer / TPA are called non-network hospitals.
Taking Advantage of the medical condition where one does not require immediate hospitalization (as it would not affect his quality of life in any way), the insured seeks preauthorization sufficiently in advance of actual admission in the hospital for treatment on cashless basis.
Policy Terms & Conditions
Terms and conditions outlining the details and the limitations of the insurance contract indicating the requirements for fulfilling or adhering to the contract of the insurance.
Authorization issued by the insurer or by the assigned TPA for admission and treatment up to a value as deemed fit by the insurer, for treatment by the hospital. To receive preauthorization one has to make a request providing the details contained in the Pre-Authorization Form.
Clarification requested to dispel any doubt pertaining to the line of treatment and the contract of insurance.
A facility under which the insured can claim the expenses borne by him during hospitalization which is otherwise claimable under his insurance contract.
Toll Free Number
A telephone number (calls to which are not charged) provided by your insurer/TPA to get in touch with them for any clarification.
A corporate body licensed by IRDA for processing and setting on their behalf, claims arising under medical insurance policies and to coordinate with hospitals for all relevant and related processes.