Page 342 - Ebook health insurance IC27

The Insurance Times

correctly about the patient's history, otherwise it may again lead to rejection of
preauthorization by TPA.
5. In case of new policies all pre-existing diseases are excluded. At the time of signing
pre-authorisation form check that doctor has not mentioned anything about condition
which may lead to assume it for pre-existing.
6. The filled up form is then sent by the hospital authorities to the respective TPA of the
company for granting of pre-authorisation of amount for hospitalization.
7. The TPA carefully scrutinises all the details such as policy number, validity of policy,
sum assured, waiting period, preexisting diseases etc and after being satisfied sends
the authorization of amount directly to the hospital.
8. After satisfying itselftheTPAwillissueapre-authorization letter/guaranteeofpayment
letter to the hospital/nursing home mentioning the sum guaranteed as payable and
also the ailment for which the person is seeking to be admitted as a patient.
9. The TPA has the right to deny the pre-authorization if he is not satisfied with the
documentation.
10. Unless the TPA gives the pre-authorization letter to hospital, the hospital will not
treat it as cashless claim. So the insured must vigorously follow-up with the TPA for
giving the authorization letter.
11. If the letter from TPA is not received or if they deny then the insured must first pay
for the expenses from his pocket and then lodge a claim to the TPA/insurance
company.
12. In case of planned hospitalization it is easier to get pre-authorisation since the insured
has ample time to followup with the TPA. The problem comes in emergency
hospitalization. Here time is of essence. The hospital will not start treatment unless
he receives authorization from TPA or cash from the insured.

346 Guide for Health Insurance