Written By: Pavitra Sampath | Updated : August 6, 2013 12:23 PM IST
Insurance companies have finally woken up to the plight of the middle class. A person who is neither rich enough to go to a high end hospital nor too poor to avail of the governments health care schemes, can now be covered by a cashless insurance scheme in nursing homes.
According to a new policy brought out by the Association of Medical Consultants (AMC), insured patients need not go to tertiary-care hospitals for minor ailments like an innocuous fever or surgery for hernia and hydrocele and can get them treated at a nursing home instead. While this is applicable only to nursing homes in Mumbai, Thane and Bhayender, we hope to see it working for the entire nation. Since people are generally unaware of what cashless insurance is all about, this post deals with some basics you should know:
What is cashless insurance?
A cashless insurance scheme is where you can avail of treatment without paying the hospital during admission. The insurance company under which you are insured will settle the bills with the hospital on your behalf.
How does it work?
Health insurance companies tie up with hospitals, after checking their quality and negotiating the rates for various procedures. These hospitals are called 'Network hospitals'. Cashless schemes will be available to you only in these hospitals. When you get a health insurance policy, which is covered under a cashless policy, you will not have to pay the hospital you get admitted to. Your insurance company that is represented by a TPA (third party administrator) will coordinate with hospital and the insurance company. To know which hospitals are under your particular insurance company's network, talk to your TPA service.
A TPA is responsible for
In order to avail of medical help under the cashless scheme you will be required to fill out a pre-authorisation form. This form will be available at the hospital's insurance desk, or on your TPA's web site. This form will be filled out by you or your family member, telling the hospital about your policy, and policy number. This form is then sent to the TPA to accept or reject your insurance claim.
There are two ways that you can avail of a cashless hospitalization policy:
Planned hospitalisation: Under this scheme, you are aware that you will have to be hospitalised in next few days and you have the time to decide which hospital you would like to avail services from. You are required to fill out the Pre-authorisation form three to four days prior to your hospitalisation date.
Here is what you should do:
Emergency Hospitalisation: This is when you require emergent care. The most important fact here is to remember to apply for your cashless mediclaim policy within 24 hrs of admission.
Things you will need to do:
What is not covered under a cashless claim policy:
Why could your claim be rejected?
Generally, a TPA will accept to pay only part of the sum required for the treatment of the patient, and settles the final bill with the hospital after the patient has been treated. In some cases if you exceed your policy assured sum, you will be required to pay the excess amount. If your policy does covers the required sum, and your TPA has not sanctioned a sum large enough to cover the initial cost of your treatment the hospital will ask for the sum to be increased.
Some things you should keep in mind:
Editor's Note:We seem to be getting comments asking for our insurance scheme. This is just an article explaining how cashless mediclaim transactions work. We are a health site and we don't sell health insurance!
