What is a General Insurance company?
General Insurance Company offers Non-life portfolios like Motor Insurance, fire insurance, Marine insurance and medical insurance. Insurance company is the one that underwrites the policy and hence it is important that the policy holder educates himself well about the policy when buying it.What is a Third Party Administrator (TPA)?
Third Party administrator is a corporate body recognized by IRDA, appointed for the administration of your medical insurance (Mediclaim) policy. TPA would therefore be responsible for processing and settlement of claims. They are also responsible for processing cashless request at network hospitals.What is Mediclaim?
Mediclaim Insurance is a hospitalization benefit policy offered by general insurance companies. This policy enables the policy holder to get the hospitalization expenses reimbursed. Alternatively policy holder can also go for cashless facility in one of the network hospitals.What are Network Hospitals?
A hospital that has an agreement with the TPA/insurance company to extend cashless facility to the Policy holder in the event of planned / emergency hospitalization.What is Cashless facility?
This facility is extended by the insurance company/ TPA to their card holders. This means the policy holder, if needs to be admitted for a surgery or in patient treatment, approaches a network hospital. The network hospital would provide him a pre-authorization request. Filled Pre-authorization form is then sent to the TPA/ insurance company. Panel of doctors at the TPA/ Insurance company would send the approval/ denial letter to the hospital.What is Pre-authorization request?
This form is available with all the network hospitals. It has two sections. First section is to be filled by the policy holder. This will have general information like Name of the patient, Age, sex, Policy Number, Card number, etc.Second section is to be filled by the doctor. This will have medical information like, diagnosis, probable duration of stay in the hospital, Approximate cost of the treatment, etc.What is Enhancement?
When the amount authorized exceeds the final bill amount, hospital would send an enhancement request to the TPA/ Insurance company.How does Cashless facility being extended?
We need to understand that the transaction is a cashless one but not free. Hospitals have been instructed to extend cashless facility only on the receipt of authorization letter from the TPA/ Insurance Company. After the hospitalization is authorized, credit bills are raised and sent to the TPA / insurance companies for payment. Policy holder enjoys benefit of not spending money from his pocket for his / her hospitalization.What do we do in case of planned hospitalization?
In case of planned hospitalization, the probable date of admission is known to the patient. The patient is advised to establish contact with the TPA help desk of the hospital. Pre-authorization request to be sent to the TPA /Insurance company at least 4 days prior to the date of admission. This minimizes last minute tensions and makes the transaction hassle free. When the cashless facility is not obtained policy holders can get their medical expenses reimbursed by submitting all the documents.