Page 159 - Ebook health insurance IC27

Sashi Publications

mediclaim policies, and now in some other newer policies also. It implies to
medical treatment for a period exceeding three days for such illness which in
normal course would require care and treatment at a hospital/nursing home,
but usually takes place confined at home due to either of the following
circumstances (i) the condition of patient is such that he/she cannot be shifted
to the hospital/nursing home or (ii) due to lack of accommodations (usually in
small towns).

(e) Cashless Hospitalization Procedure - Cashless facility is offered to the customers
through the insurers' in-house channels or Third Party Administrators (TPA), who
coordinate with the customer and the hospital to ensure that the admissible bills are
not required to be paid in the hospital by the customer, but directly settled by the
TPA/insurer in due course. Admission should be taken in a listed hospital in the
empanelment list oftheinsurer/TPAandis subject to pre-authorizationbeing granted
by the insurer/TPA. The TPA , validates the claim and need not necessarily always
approve the claim, and ask for more information/documents or may even reject the
claim. However, denial of cashless facility does not reflect on the admissibility of
claim, and the customer can submit the papers directly to the insurer/TPA.

(f) Deductibles - They are a cost sharing mechanism. These are the initial amount
of admissible claim which must be borne by the insured.

(g) Co-payment or Co-insurance - In the Indian context, these terms are used
interchangeably to reflect the percentage of risk that the insured is required to
bear

(h) General Waiting Period - Normally all the products have a waiting period of
30 days , wherein a customer cannot make a claim , except for accidental cases,
and in case of renewals. This is basically to avoid someone taking a policy to get
coverage for impending treatment/hospitalization.

Website : www.bimabazaar.com, PH: 033 22184184/40078428 163