Page 226 - Ebook health insurance IC27

The Insurance Times

Under cashless hospitalisation insurance company directly pays the claim amount to
hospitals. However prior authorisation is required for cashless treatment.

Insurance company can establish its own claim processing department or tie up with a
TPA. A hospital which has a tieup with TPA is known as the network hospital.

Insurance company will pay the claim even if the TPA does not have tieup with hospitals,
only the minimum conditions as to number of beds, licensed must be satisfied.

There are two methods for getting a claim under a health insurance policy
1. Cashless Hospitalisation
2. Non-cashless Hospitalisation

Cashless claims can be of two types

a. Planned- Where the insured is aware of the hospitalisation 2-3 days in advance.
In such cases the insured must obtain pre-authorisation from the TPA for getting the
cash less facility.

b. Emergency- When the insured or any family member meets an accident or a sudden
illness that requires immediate hospitalisation, he can get himself admitted in the
network hospital of the TPA and then approach the TPA for authorisation for cashless
payment.

 In case of indemnity policies the insurance companies pays for all the treatment
expenses incurred by the insured subject to the sum insured.

 In case of benefit policies the insured is paid prespecified lump sum amount regardless
of the actual expenses incurred.

 If the insured does not submit all the claim documents the claim may be repudiated
or partially paid due to want of supporting documents for expenses.

230 Guide for Health Insurance