When 38-year-old Santosh Balan, a senior private sectorexecutive, was faced with a medical emergency concerning his wife,settling the hospital bill was the least of his concerns he had thenecessary medical cover.
But an overlooked lapse in procedure almost cost him a tidy sum. At the time of discharge, the third party administrator (TPA) hadnot processed the claim or intimated the expense limit to thehospital a standard procedure for those who opt for a cashlesshealth cover, recalls Balan. As a result, Balan had to extend hiswife's hospital stay by a day to enable the TPA to process andsettle the claim with the hospital.
Cashless health insurance is a boon in times of medicalemergencies. The key to an effortless claim settlement is the TPAappointed by the insurer to see your claims and accelerateprocessing hospital bills.
Outsourcing the claims processing function to TPAs can createproblems if there's poor liaison between TPAs and hospitals. For thecustomer, a TPA is a non-entity as he bought the policy from theinsurance company, says Shreeraj Deshpande, Head (Travel and HealthInsurance), Bajaj Allianz.
Cashless policies allow customers to get medical treatmentwithout paying cash upfront to the hospital or pay hefty bills atthe time of discharge. That can be a load off one's back,especially in times of emergencies when the entire focus is on thepatient's life, says Ritesh Kumar, Head (Retail), ICICI LombardGeneral Insurance. However, as both Deshpande and Kumar admit, it'sa facility and comes with its own set of conditions.
The anatomy of cashless insurance
What the fine print does not tell you, and what it does.
Cashless facilities are available only at approved or networkhospitals of the insurance company. At others, you can claimreimbursement after settling the hospital bills
Certain illnesses/diseases may not be covered either by theinsurer or under your policy
Certain illnesses/diseases may be covered only after the firstyear of insurance
Existing illnesses/diseases are usually not covered by the policy
Risk of delayed response by TPA, especially if the insurer hasoutsourced the function. A TPA usually handles several insurers, andso, may not be able to give individual attention to each case
Problems like delays in either starting treatment or dischargemay arise if there is poor liaison between TPA and hospital
You have to be hospitalised for a minimum of 24 hours to avail ofthis facility unless it's a highly specialised surgery like cataractin which case the 24-hour condition is waived
For one, a cashless health insurance policy is valid only athospitals accredited with the insurance company. At non-networkhospitals, a customer has to settle the bills on his own and canthen claim reimbursement, says Deshpande.
Secondly, insurers initially authorise limits up to which you canclaim cashless benefits and which could see you scuttle from pillarto post to increase the limit.
Decoding cashless
In cashless health covers, insurance companies tie up withhospitals and agree to settle the patient's bills after discharge. Acashless pre-authorisation form is kept with the hospital, which hasto be signed by the insured and vetted by the doctor.
The completed form is sent to the TPA who, depending upon theterms of the policy, will issue an Authorisation or a Denial Letterto the hospital and also spell out the expense limit. Cashlesspolicies cover two kinds of hospitalisation procedures planned andemergency.
In case of a planned hospitalisation, the authorisation from theTPA could take anywhere between 24 and 48 hours while in case of anemergency, it could take six hours, says Kumar, adding that suchpolicies also cover 30 days preand 60 days post-operative careexpenses.
What's not covered
While most illnesses are covered under cashless policies, it isimportant to know the exclusions. Says Ajay Bimbhet, MD, RoyalSundaram Alliance Insurance: Exclusions include pre-existingdiseases, heart, kidney and circulatory disorders in respect ofinsured persons suffering from preexisting hypertension or diabetesand it is up to the TPA to determine whether a particular illnesscan be covered under the scheme or not.
Additionally, he says, people who opt for a cashless insurancepolicy have access to a 24-hour helpline number and an ambulancereferral facility au gratis. Says Bimbhet: The biggest advantage toa customer is the hassle-free discharge facility as he need not runaround arranging for finances at a difficult time. Keep a list ofthe network hospitals for treatment and the emergency helplinehandy. Perhaps it's what the doctor ordered for your health andhappiness.
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