Availing Cashless Hospitalization in Pune, Then you must read this…

The customer would be able to avail the cashless facility if he undergoes hospitalization in Pune and or surgery at any of the TPA empanelled medical centers of his choice.This means, in the event of hospitalization and or surgery in any of the network hospitals, the customer doesn’t have to pay for the treatment in cash. The TPA on behalf of the Insurer shall pay the approved eligible amount of Daily Hospitalization Benefit & Surgical Benefit as per the plan directly to the hospital, as settlement of the customer’s dues, if the policy provides for a higher amount on the covered illness and treatment, the TPA would pay the customer the difference amount. In case of admission in a non-network hospital, the TPA shall directly pay the customer, the approved eligible amount of Daily Hospitalization Benefit and Surgical Benefit as per the policy provisions.

​Availing Cashless hospitalization in Pune is when the insured person doesn’t have to pay a single penny out of his pocket in case of a hospitalization or surgery and the entire hospital bill is cleared directly by the Insurance Company.

For the cashless policy, the Health Insurance companies collaborate with a list of hospitals after checking the quality of service they offer and discussing the rates of different medical treatments. Such hospitals are called as the ‘Network Hospital’ of the respective Insurance Company. If you purchase a Health Insurance policy​ from a particular company, you are eligible for cashless hospitalization in Pune only when the particular hospital is listed in their network hospitals.

Every Health Insurance company​ is represented by a Third Party Administrator (TPA) which will be a mediator between the Insurance Company and the hospital. It is the TPA’s responsibility to accept or reject claims and coordinate between the hospital and the Insurance Company

For availing the cashless hospitalization facility in Pune you need to fill a pre-authorization form which is available at the Hospital or the TPA’s website. This form is filled by the patient’s relative to inform the TPA about the claim. They would need to provide your policy number and the nature of your treatment. Once the TPA receives the claim they investigate about the authenticity of the claim and accept or reject it.​

What is authorisation?

Authorization refers to the process where your health insurance provider or TPA approves of the claims that have been put forward by you for cashless hospitalization. It may be noted that it could take a minimum of 24 hours for the claims to be verified and approved. If the reasons why you get admitted to a network hospital have to do with planned surgeries, you would necessarily have to get authorization from your health insurance provider. However, if it were an emergency that you get hospitalized for, the processing would be done at the earliest possible time frame lack of authorization would not be a reason for claim rejection in such cases.

There are two Ways Cashless Health Policies in India can be Utilized

1. Planned Hospitalization

After getting a recommendation from the doctor, one can check out the network hospitals and select the best one. After that, one needs to get in touch with the third party administrator (TPA) of his insurance company with required pre-hospitalization paperwork. TPA will study his case, and if everything is in order, it will begin the process of providing cashless hospitalization to the patient.

2. Emergency Hospitalization

This is where most people feel the financial crunch. Arranging cash for admission process in a short span of time while at the same time getting treatment started for the family members or self-becomes a huge challenge. However, even in this case you need to contact the TPA desk and provide them with your id and other details. Based on that they will evaluate your case and get permission from the insurance company. In emergencies, the turnaround time for them to give you a yes or no is approx 6 hours and in other cases; they have to get back to you within 24 hours. With cashless insurance, health insurance policies in India have come to the rescue of millions for whom getting expensive medical treatment is nearly impossible.

In both the above-mentioned cases, you need to keep photocopies of all documents, hospital bills, doctor reports, etc. as the originals will be submitted with the TPA for claim processing. Only if your claim amount surpasses the sum assured as per the policy that you will have to pay the extra amount on your own and that too later, at the time of filing the claims, not immediately. To ensure claims are not rejected, give correct information while submitting the request.

Advantages of Cashless Hospitalization

1. You can start the best possible medical treatment without spending a single rupee from your pocket
2. Except for non-medical administrative expenses and cost of medicines, every other expense could be covered under the plan
3. Certain insurance companies provide this feature on your policy even if you’re travelling abroad
4. You can claim tax benefits on cashless health insurance under section 80D
5. Some insurers also offer free medical check up at regular intervals

The best health insurance plan is one that not only covers your medical expenses, but also comes to your rescue in case you need instant hospitalization with not enough cash in your hand. You can enjoy ​Cashless hospitalization too by planning to get a cashless insurance cover.

What do you mean by Network / Non-network Hospitalization?

A Hospital empanelled by the TPA, which has an agreement with TPA for providing Cashless treatment, is referred to as a ‘Network Hospital’. List of network hospital is available in user guide / TPA website. Cashless facility is provided ONLY at the network hospitals. Non-network hospitals are those who are not empanelled by the TPA and any policyholder seeking treatment in these hospitals will have to pay for the treatment and later claim the same from TPA on submission of the mandatory documents and subject to the company policies and eligibility –For complete details please refer to your policy document.

What is the benefit of carrying a health card?

1. The Health Card is needed for identification of the insured by the network hospital for requesting the cashless facility. This means you can walk into any of the network hospitals across the country and get treated without having to pay for your bills first and then claim from the TPA.
2. Also in the event of any unforeseen accident a third party can identify your Insurance Company and your family can be intimated.
3. The Health card carries unique member number which helps track the status of any claim by the TPA faster.

How does Cashless access work?

Each person covered under the Policy will be issued a Health card. In case of planned hospitalization, the policyholder should obtain an Authorization Letter from TPA by faxing the pre-authorization request. The pre-authorization form would be available with the Network Hospital/website/TPA offices. It should be filled up with all the relevant details (policy no. /telephone no. /bank account no. /past history, etc) authenticated by the treating physician.The authorization letter issued by the TPA post scrutiny of the pre-authorization request; will indicate the name of the insured/patient, the name of the hospital where treatment is required, the nature of illness/disease for which treatment is required and the monetary limit above which the insured/patient will have to pay. The policyholder will have to submit this authorization letter along with the identity card given by TPA to the admission counter in the hospital. In case of Emergency Hospitalization, the Hospital would fax the pre-authorization request to the TPA as above.

What are the points one must note while getting hospitalized under the cashless access service?

1. Obtain pre–authorization form from Insurance Help desk 3–4 days prior to the Admission for planned hospitalization.
2. Show your TPA identity card and the Authorization letter given by TPA. The hospital will check the ID card and authorization letter.
3. All the details in the ‘Pre –authorization form’ should be correct and to be filled in by treating doctor.
4. Check about the pre–authorization approval at the Insurance help desk within next 24hrs.
5. You can avail cashless treatment at the hospital after receipt of written authorization from TPA for the covered.
6. Some network Hospitals may charge you registration fees / admission fees etc.
7. These will have to be paid by the policyholder as these are not covered under the policy.
8. Leave back all the original documents and signed claim form with the hospital at the time of discharge.
9. Contact local TPA office in case of any query.
10. Make payment to the hospital for the expenditure over and above the TPA approved limit and for the treatment not covered under the package.

Please note: The information presented above is for informational purpose only.