TPA and Cashless Facility...

We have the following TPAs attached with us for cashless facility:

Medi care Services India Pvt Ltd.

Dedicated Health Care Services Pvt Ltd.

Focus Health Care Pvt Ltd.

Safeway Mediclam Services.

Good Health Plan Pvt Ltd.

Shree Gokulam Health Services TPA(P) ltd.

Anyuta Medinet Healthcare Pvt Ltd.

Parekh health Management Pvt Ltd.

M D India Healthcare TPA Services Pvt Ltd.

Alankit Health Care TPA Ltd.

Health India TPA Services Pvt. Ltd.

Heritage Health TPA Pvt Ltd.

Cholamandalam General Insurance co.

ICICI Lombard TPA Pvt Ltd.

Does cashless hospitalisation 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 hospitalisation, the insurance company will bear the cost of treatment either fully or partially on your behalf.

Cashless hospitalisation 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 hospitalisation. The hospital is only a facilitator and has no authority to approve or disapprove any request for cashless hospitalisation. Certain protocols laid down by the Insurance Regulatory and Development Authority (IRDA) with respect to cashless hospitalisation will need to be adhered to strictly.

What procedures should I follow to avail the facility of cashless hospitalisation at gagangiri hospital?

Hospitalisation happens under two circumstances Planned and Emergency. Pre-authorisation of the estimated hospital expense is a must to avail this facility.

Planned Hospitalisation:

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 hospitalisation. 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 hospitalisation.

In case you have not applied for a pre-authorisation sufficiently in advance or if the doctor treating you advises you to get hospitalised immediately after the consultation, our Corporate Help Desk will assist you through the pre-authorisation procedure.

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

The pre-authorisation procedure is detailed below:

Step 1: Establish contact with the Corporate Help Desk at the Hospital

Step 2: At the Corporate Help Desk, you need to present the original health Insurance card issued to you by your TPA

Step 3: Collect the pre-authorisation will forms pertaining to your TPA

Step 4: Your pre-authorisation will have two sections-

i. 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)

ii. Pertains to the treatment recommended for you-needs to be filled in and duly signed by the Doctor who is treating you (do not attempt to fill this section, contact the Corporate desk in case of any difficulty)

Step 5: 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

Step 6: Once the form is complete in all respects, the Corporate Help Desk will fax the form to the office of your TPA.

Step 7: The Corporate Help Desk will revert to you on the approval status

Emergency Hospitalisation:

In case of emergency hospitalisation, the corporate help desk will take up your case on a fast track basis with your TPA.

For cashless treatment it is mandatory for the hospital to have an approval from your TPA. Incase 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.

What do I do if I do not get approval on my cost of treatment till the time of discharge at the Hospital?

Cashless hospitalisation is linked to the approval of the estimated expenditure on your proposed treatment. In case you do not get your approval you will need to bear the entire expenditure incurred on the treatment. Therefore it is always prudent to get the approval and then get yourself admitted. You could explain the benefits of getting the approval before the date of your admission to your treating doctor as well when he recommends an immediate admission.