Your easy guide to avail cashless Hospitalization

Do all Health Insurance Policies offer cashless hospitalization facility?

Today, most Health Insurance policies do offer cashless hospitalization facility and route your policy through a Third party Administrator (TPA). However you should be familiar with the terms- Network Hospital and Non-network Hospital.

Network Hospitals are those hospitals that your TPA has an agreement with. In case of hospitalization, if you get admitted to a Network Hospital you will be eligible for cashless hospitalization, subject to the other terms and conditions mentioned in your policy being fulfilled. In case you are admitted to a Non-network Hospital, you will have to settle the bills directly to the hospital and then seek re-imbursement through your TPA.

Does cashless hospitalization mean I can just walk into a hospital and get admitted for treatment free of cost?

First, you need to be clear that there is no free treatment. It is just that, in the case of a cashless hospitalization, the insurance company will bear the cost of treatment either fully or partially on your behalf.

Cashless hospitalization is a facility provided by most health insurance policies and enables an insured customer to obtain admission and undergo the required treatment without a direct payment. The assigned TPA will mediate between the healthcare service provider (Hospital) and the Insurance company and settle the bills on behalf of the insured customer.

However it is important to understand the role of a Hospital in cashless hospitalization. The Hospital is only a facilitator and has no authority to approve or disapprove any request for cashless hospitalization. Certain protocols laid down by the Insurance Regulatory and Development Authority (IRDA) with respect to cashless hospitalization will need to be adhered to strictly.

What procedures should I follow to avail the facility of cashless hospitalization at Sanjeevani?

Hospitalization happen fewer than two circumstances – Planned and Emergency. Pre-authorization approval of the estimated hospital expense is a must to avail this facility.

Planned Hospitalization

In the case of a planned admission, you would have first consulted a doctor who in turn would have advised you on the probable date of hospitalization. In such a case, you must have applied for an approval of the estimated hospital expenses directly with your TPA at least 4-5 days prior to the date of hospitalization.

In case you have not applied for a pre-authorization sufficiently in advance or if the doctor treating you advises you to get hospitalized immediately after the consultation, our Insurance Cell will assist you through the pre-authorization procedure.

However, you will need to bear in mind that the Insurance Cell is only a facilitator and can in no way influence the decision on the approval. The approval can be turned down.

The pre-authorization procedure is detailed below

• Establish contact with the Insurance Cell at the Hospital
• At Insurance Cell, 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 produce your photocopy of employee ID card if it is a corporate group insurance policy.
• 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 Insurance Cell 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 (do not attempt to fill this section, contact the Insurance Cell in case of any difficulty)
• general details on the health Insurance policy – to be filled in by you (the Insurance Cell 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 (do not attempt to fill this section, contact the Insurance Cell in case of any difficulty)
• Return the completed form to the Insurance Cell. 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 Insurance Cell will fax the form to the office of your TPA.
• The Insurance Cell will revert to you on the approval status

Emergency Hospitalization

In case of emergency hospitalization, the Insurance Cell will take up your case on a fast track basis with your TPA and is likely to receive approvals within 3 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 when you cannot wait for receiving the approval owing to medical urgency you can undertake the treatment by paying the necessary cash deposit.

If you receive approval from your TPA after paying the cash deposit, you are entitled for refund of the cash deposit.

Does cashless hospitalization cover all medical expenses?

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 / Attendars Charges
• Ambulance Charges.
• Charges for Diet, which is not part of the administered treatment
• Document Charges.
• Toiletries.
• 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, what are the documents the hospital requires from me 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.