Mediclaim Awareness
Mediclaim is an insurance against illness, for treatment in hospitals. General insurance companies offer a hospitalization benefit policy that enables the policy holder to get the hospitalization expenses reimbursed. The policy holder also has the advantage of cashless facility in any one of the network hospitals.
Third Party Administrator (TPA) is a corporate body recognized by IRDA (Insurance Regulatory & Development Authority of India) which has the expertise and capability to administer all or a portion of the claims process. Generally, a health insurer or self-insuring company enter into a contract with a TPA to administer services, including claims administration, premium collection, enrolment and other administrative activities. A hospital or provider organization while setting up its own health plan often outsources certain responsibilities including processing and settlement of claims to a third-party administrator. A TPA is also responsible for processing cashless request at network hospitals.
Network Hospitals are part of a tie up system involving health insurance providers and hospitals. To ensure profitability and avoid incurring unnecessary losses, health insurance providers collaborate with certain hospitals, making them a part of their network.
Considering which hospital maximum number of policyholders go to in specific areas, insurance companies negotiate treatment and stay costs with their select network hospitals to avoid unnecessary escalation of bill amounts.
These chosen network hospitals become a part of the broad hospital network that specific insurance companies are associated with. Policy holders also get the benefit of cashless payment of bills at select hospitals which come inside this mutual network.
Cashless Facilityis an added advantage for a Mediclaim card holder. If the policy holder needs to be admitted for a surgery or in patient treatment, the network hospital will give him / her a pre-authorization request form which is to be filled and sent to the TPA/ insurance company. The panel of doctors at the TPA/ insurance company will send the approval / denial letter to the hospital. A policy holders has to apply for reimbursement to the TPA / insurance company after settling the final payment for treatment or surgery himself / herself in a non-network hospital.
Transaction Under Cashless Facility is not free. Hospitals have instructions to extend cashless facility only on the receipt of authorization letter from the TPA/ insurance Company. After the authorization of the hospitalization, credit bills are raised and sent to the TPA / insurance companies for payment. The advantage is that the policy holder doesn’t have to pay from the pocket the bill amount for his / her hospitalization; it will be deducted from the insurance coverage.
Pre-authorization Request Form is available with all the network hospitals.
The form consists of two sections. The policy holder has to fill the first section which contains general information like name of the patient, age, sex, policy number, card number, etc.
The concerned doctor has to fill the second section which contains medical information like, diagnosis, probable duration of stay in the hospital, approximate cost of the treatment, etc.
Enhancementcan be availed in an health insurance cover when he amount authorized exceeds the final bill amount. The hospital will send an enhancement request to the TPA/ insurance company. For enhancement of expenses approval must be obtained before patient is discharged.
Planned Hospitalization allows a patient ample time to plan an admission to the hospital. For example, if the doctor advises a surgery for cataract tany time in the next few weeks, the patient has time to plan the hospitalization. Once the patient comes to know the probable date of admission, the next step is to contact the TPA help desk of the hospital. Pre-authorization request must be sent to the TPA / insurance company at least four days before the date of admission. This minimizes last minute tensions making the transaction hassle free. In case, the cashless facility is not availed, policy holders can get the medical expenses reimbursed by submitting all the documents.
Emergency Hospitalization happens because of an unforeseen situation, such as a road traffic accident or a sudden attack of illness. One cannot plan for such hospitalization.if it is an emergency hospitalisation, the claim intimation must be sent to the insurance company within 24 hours.
