Guideline to avail cashless* Hospitalization
Nowadays, most Health Insurance companies offer the facility of cashless* hospitalization and the policies are enrooted through a Third party Administrator (TPA). However the policy holders need to aware of the term “Network Hospitasl and Non-network Hospital”. Network Hospitals are those which your TPA got an agreement. If you get admitted to a Network Hospital you are entitled to cashless* treatment, subject to the terms and conditions mentioned in the policy. If the policy holder gets admitted to a Non-network Hospital, he needs to pay the bills to the hospital and then re-imbursement to be sought through his TPA.
Cashless doesn’t mean free treatmentThere is nothing called free treatment. As a matter of fact in the case of a cashless* hospitalization, cost of treatment either fully or partially will be borne by the Insurance Company on behalf of the Policy Holder. The assigned TPA is the mediator between the Hospital and the Insurance Company in settling the bills on behalf of the policy holder. The policy holders must understand that the Hospital is only a facilitator and has no authority to approve or disapprove any request for cashless* hospitalization. Certain protocols lay down by the Insurance Regulatory and Development Authority (IRDA) with respect to cashless* hospitalization will need to be adhered to strictly.
Procedures need to be followed to get the facility of cashless* hospitalization at Charnock Hospital, Kolkata:
Hospitalization takes place normally under two circumstances – 1) Planned and 2) Emergency.
In case of a planned admission, one needs to first consult a doctor who will advise the patient on the probable date of hospitalization. In such a case, the policy holder must apply for an approval of the estimated hospital expenses to the TPA at least a week prior to the scheduled date of hospitalization. In case of you face any difficulties our Corporate Help Desk is there to assist you through the pre-authorization procedure. But you need to understand that the Corporate Help Desk is only a facilitator and can in no way decision on the approval can’t be influenced by them. The approval can also be turned down by the TPA.
Procedure of the Pre-authorisation is as following:• To contact the Corporate Help Desk at the Hospital
• At the Corporate Help Desk, you need to present the original health Insurance card issued to you by your TPA. And also produce a photocopy of ID proof issued by Govt. Authorities (PAN card/ Driving Licence/Voter ID card etc).
. Addition to this please produces your photocopy of employee ID card if it is a corporate group insurance policy.
• To collect the pre-authorization forms pertaining to your TPA
• Your pre-authorization will have two sections - general details on the health Insurance policy - to be filled in by you (the Corporate desk will assist you in case you have any difficulty) pertains to the treatment recommended for you-it needs to be filled in and duly signed by the Doctor who is treating you
• Return the completed form to the Corporate Help Desk. The personnel at the desk will verify the form for its completeness and let you know in case of any discrepancy
• Once the form is complete in all respects, the Corporate Help Desk will fax the form to the office of your TPA.
• The Corporate Help Desk will revert to you on the approval status.
Emergency HospitalizationIn case of emergency hospitalization, the corporate help desk will take up your case on a priority basis with your TPA and is likely to receive approvals within few 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 if you cannot wait for receiving the approval owing to medical emergency you can avail the treatment facility by paying the necessary cash deposit. If the approval is received from your TPA after paying the cash deposit, you are entitled for refund of the cash deposit. However, Corporate Help Desk at Charnock Hospitals will not entertain any request for a refund of the amount paid if the approval comes after the process for your discharge has commenced.
Circumstances when request for cashless Hospitalization are rejected :
• The ailment for which hospitalization is being sought by you is not covered under your insurance policy for reasons like pre-existing ailment, specific exclusions (road traffic accident under the influence of Alcohol)
• Information contained in the pre-authorization form is insufficient for the TPA to arrive at a decision and further information is not available for various reasons. However the chances of rejection under this criterion are rare since the Corporate Help Desk at the hospital is experienced in complying with pre-authorization formalities and will advise you suitably
• You have exhausted your eligible Medical Insurance cover for the year.
In case your hospitalization expenses exceed the pre-approved amount, you can approach the Corporate Help Desk to apply for an enhancement of the pre-approved amount. The Corporate Help Desk 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.
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.
• Registration / Admission Fee
• Telephone Charges
• Visitors / Attendant Charges
• Ambulance Charges.
• Charges for Diet, which is not part of the administered treatment
• Document Charges.
• Non-medical Expenses.
• Service Charges
These need to be settled by you directly to the hospital at the time of discharge
In case of cashless* hospitalization, 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, as those need to be submitted to the TPA for the hospital bills settlement.