The facility of cashless claims in health insurance tries to remove the problems associated with settling hospital bills and making lump-sum payments for hospitalisation. The facility can be availed of only if the hospital, where the patient is to be treated, figures among the hospitals approved by the insurer. The list of network hospitals can be obtained from the TPA (third-party administrator) either from its website or by calling its toll-free number. The details of TPA are available in the health insurance policy.
Informing the hospital
The hospital needs to be informed at the time of admission that the patient is covered under cashless health insurance policy and the insurance card needs to be submitted at the admission desk for this purpose.
The form is available with the hospital and has to include the approximate hospitalisation cost based on an estimate from the admission desk. If the hospitalisation is planned, it is advisable to finish the pre-authorisation procedure beforehand.
On receiving the pre-authorisation form, the TPA checks the policy limits, eligibility and riders applicable in order to accept or reject the claim. After approval, the TPA sends an initial authorisation by fax to the hospital.
At the time of discharge, the insured has to sign the discharge form and all the bills and forms, which are sent by the hospital to the TPA for authorisation. If this authorised amount is less than the hospital bill, the difference needs to be paid by the policyholder to the hospital.
Points to note
> Even if a pre-authorisation request is denied by the TPA, the insured can go ahead with treatment, settle the bills and then apply to the insurer for a possible reimbursement.
> In case of an emergency hospitalisation, the pre-authorisation form has to be faxed to the TPA in the duration specified.
> Non-medical bills and expenses not covered must be settled directly by the insured before discharge.