FAQ – Frequently asked questions
Today, most health insurance policies offer cashless hospitalization facility and route your policy through a Third party Administrator TPA).Network hospitals are those hospitals that your TPA has an agreement with. If you get admitted to a network hospital you will be eligible for cashless hospitalization, subject to the conditions mentioned in your policy. When you get the approval for cashless hospitalization, the insurance company will bear the cost of treatment either fully or partially. This enables an insured customer to obtain admission and undergo the required treatment without direct payment. In case you are admitted to a non-network hospital, you will have to settle the bills directly to the hospital and then seek reimbursement through your TPA.
Approval and pre-authorization by your TPA is essential for cashless hospitalization. The hospital has no authority to approve or disapprove cashless hospitalization. The assigned TPA will mediate between the hospital and the insurance company and settle the bills on behalf of the insured customer.
The estimated hospital expenses must be Pre-authorised by TPA.
Here is the procedure for Pre-authorisation.
In case of emergency hospitalization, the Insurance Help Desk will take up your case on a fast track basis with your TPA and is likely to receive approvals within 24 hours during working days. 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 undergo the treatment by paying the necessary cash deposit. If you receive approval from your TPA, you are entitled for refund of the cash deposit.
In case you do not get your approval you will need to bear the entire expenditure incurred on the treatment. you will have to settle the bills directly to the hospital and then seek reimbursement through your TPA. Therefore it is always prudent to get approval before admission.
If the ailment for which hospitalization is being sought is not covered under your insurance policy for reasons like pre-existing ailment or specific exclusions or you have exhausted the eligible medical insurance cover for the year.
You can approach the Insurance Help Desk to apply for an enhancement of the pre-approved amount. 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 discharge.
Pre authorisation does not guarantee that all expenses will be reimbursed. Please note that the type of room and room rent will depend on the package approved by TPA. The expenses listed below are not reimbursable under cashless hospitalization. Registration / Admission fee, Telephone charges, Visitor / Attender charges, Ambulance charges, Charges for diet, Document charges, Toiletries, Non-medical expenses, Service charges, These charges are not covered. These need to be paid by you directly to the hospital at the time of discharge
In case of cashless hospitalization, what are the documents to be submitted 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.
Please contact Insurance Help Desk, at The Reception, Sri Balaji Clinic for all assistance regarding your Insurance claims.