Cashless claims for medical emergencies :: Business Line

Every insurance company has list of approved hospitals with which they have tie-ups for cashless claims facility.

A medical emergency is probably the most stressful situation you can face. Most people buy medical insurance to avoid financial crunch and hassles during such emergencies.

A cashless facility entails the insurance company directly arranges to pay your medical dues to the hospital.

But in many situations the insurance companies refuse to pay for the medical expenses at the time of treatment or beforehand. A few careful steps will make sure your cashless claims go through smoothly.

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APPROVED HOSPITALS

First, choose the right hospital to admit the patient. Every insurance company has list of approved hospitals with which they have tie-ups for cashless claims facility. If you happen to get admitted to any other hospital which is not listed with the insurer, one has to first settle the bills with the hospital and then later apply for re-imbursement from the insurance company with all bills in original.

The insurance company may assess the same and would reimburse the insured within a stipulated time. So refer to the company’s list of approved hospitals well before time so as to avoid last minute hassles to manage the required funds.

INFORM THE INSURER

Two, inform the insurer. Before you get admitted to the hospital, there is a specific time frame before which you need to inform the insurance company about your case and the details of the hospital you are getting admitted to.

This time period may vary from company to company. After your hospitalisation, you need to inform the insurance desk of the hospital. In case there’s no such desk, usually the hospital’s accounts division takes care of such activities.

Three, there is paperwork. After approaching the desk you need to ask for pre-authorisation form for cashless facility. You need to accurately fill out information such as the exact nature of the medical problem, the date of hospitalisation, the expected cost of the treatment (which would be provided the hospital), expected duration the patient would require to be hospitalised before and after the treatment.

After filling up the form, you need to get it approved and stamped by the hospital and then get it faxed to the insurance company or the Third Party Administrator (TPA) nominated by the insurance company.

After assessing your form, the insurance company may make an internal estimate of the treatment and hospitalisation expenses and would arrive at a total figure for cashless claim.

The amount might be lesser than what you claimed. In this case, you will have to adjust what is approved by the insurance company against the total bill and pay the balance bill amount yourself.

You can, after the discharge, approach the insurance company with all original bills and get the balance amount of the claim (that you paid) also reimbursed.

You can also get the balance amount before the patient gets discharged but the process may unduly delay the discharge of the patient by 3-4 hours which the insurance company usually takes to assess the bills.

If you follow this process, and keep in touch with the insurance company throughout the hospitalisation, there’s only a rare chance that your claim would get repudiated.

(The author is Senior Vice-President-Bonanza Portfolio)