Getting Treatment sans cash

Source: Dalal Street Investment Journal

Cashless settlement in health policies is marred by various issues. Jay Sampat tells you how one can avoid pitfalls while going for cashless claim

My colleague Indraneil initiated the claims process towards his father's IFFCO Tokio Health Insurance Policy after his 60-year-old father was advised a bypass heart surgery. He intimated the diagnosis to the third party administrator (TPA) Paramount Healthcare with the help of the hospital .While the insurance claim process started a week before the surgery, the authorization did not materialise in time. Indraneil was banking a great deal on Rs 3 lakh from the policy. However, the relief came late and he had to take a personal loan and clear the bill on his own.

Such experiences are common while raising a health insurance claim; claims getting stuck due to bureaucracy, mistakes/omissions while filling the form and wrong spellings in the initial policy, among other things. To avoid getting stranded, one should try and understand the processes involved and follow them to the hilt. For starters, store the TPA's number in your mobile. Next, choose one of the approved hospitals for your treatment. If you don't have the list, call up your TPA for help before you get admitted because if you go to a hospital that isn't part of the network, you will have to pay the bill upfront and file for a claim with the TPA later. While most of the well-known hospitals are well networked with insurers, you will need to follow the reimbursement method with small clinics that aren't listed. In such cases, keep the Documents safely and tell your family members where they are kept so that one is not stranded in case of an emergency.

In the hospital, show your TPA card and fill the authorization form. The hospital will then send the budget based on the prognosis to the TPA. The TPA will check the documents and approve or reject the authorization. In the meantime, you will be admitted to the hospital and your treatment will begin. However, whether you need to pay or not will depend on the authorization. If the TPA authorizes the claim, the policyholder does not have to shell out a rupee as the hospital directly settles the final cost on discharge with the TPA. But if the claim is rejected, the policyholder has to settle his dues with the hospital and follow up with the TPA later.

While this procedure seems like child's play, there are several hiccups which one may run into. Serious issues could be incorrect or incomplete information furnished by the hospital, no notice about renewal of the policy from the insurer to the TPA, your data with the TPA not matching
with your hospital data, etc. On the other hand, trivial issues may range from servers being down, to the officer handling your account being on leave! While some things are beyond
your control, being up-to-date in the claims process can make matters easier for you. Additionally, you need to know very well what your policy covers such as limits on the room
rent, doctor's fees and medicines, for instance.

On Cashless Mediclaim

1. Initiate the claims process soon after treatment and likely duration of hospitalization is known.
2. It takes 7-15 working days for authorization to come through.
3. Take the pre-authorization form from the hospital and submit it.
4. Hospital subsequently takes up your case with the TPA.
5. TPA, which has all the relevant details of policy holder, authorizes the cashless claim / returns the form with appropriate comments.
6. Policyholder undergoes treatment and hospital submits bills to TPA for final settlement.
7. If authorization is delayed/rejected you may need to pay the money and get reimbursed later.
8. Keep all necessary papers like prescriptions, diagnosis, reports and discharge card ready to show to your TPA.
9. In case of an emergency, get admitted by paying a deposit and initiate the claims process simultaneously with the TPA.
10. If there is an emergency, you need to get in touch with the call centre at the earliest. Once the call centre is alerted, the TPA is supposed to follow it up with the hospital for the pre-authorisation. This seldom happens and hence you will have to follow-up.

Take-home - In most cases, hospitalization is pre-planned and hence the insurance process
can be planned in advance. Start by initiating the process at least a week in advance, since authorization is valid for 15 days to a month. Also, remember to keep all the relevant documents
like doctor's prescriptions, diagnosis reports and hospital bill ready as they are required in original and duplicate, especially if your claim is rejected and you have to re-submit papers. Last,
but not the least, keep a family member in the loop at every stage in case of unforeseen circumstances.

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