The Hindu Business Line : Cashless cover

Illnesses have a way of sneaking up on us, weakening our financial stability and snatching our family’s peace of mind. A sound health cover plan should ensure that your medical expenditure is met without much ado as soon as the need arises. A sound health plan will cover a wide spectrum of medical conditions and provide long-term coverage. Also, the policy should be backed by a trusted name that gives the assurance of paying claims.

Earlier, an insured had to fall back on a TPA/DSP (Third Party Administrator/Direct Service Provider) to take care of the hospitalisation requirements. A TPA or DSP is an intermediary which co-ordinates with the insurer, the hospital, and the insured for processing and settling the claim. The policy holder had to settle his/her medical bills with the hospital and then claim reimbursement from the TPA/DSP.

Realising that patients are often hard-pressed when it comes to making upfront payment to get admission and treatment as well as settling bills at the time of discharge from hospital, life insurers are now offering cashless health cover.

In a cashless facility, the company takes care of the surgery/hospitalisation expenses payable, as per the said benefit under the policy. Every insurance company has a tie up with a large number of hospitals in each city. They are termed as network hospitals and the excluded hospitals are usually called the non-network hospitals.

A list of network hospitals is provided to each policy holder at the time of availing the policy. He can also avail of the same from his TPA/DSP. Based on the convenience and doctor’s recommendation, a policy holder can get hospitalised in a network or a non-network hospital. While reimbursement facility is applicable to both, the cashless facility is available only at the network hospitals.

In the case of cashless hospitalisation with network hospitals there could be two situations — planned hospitalisation or emergency hospitalisation.

Planned hospitalisation

Planned hospitalisation is planned and authorised well in advance. This is useful in case of planned treatments/surgery for ailments such as bypass surgery, cataract, and hernia to avoid last minute inconvenience and confusion. The policy holder needs to fill up a pre-authorisation form, available in the policy kit, at branch, with DSP or from Web site and hand over the same to the doctor before admission. The hospital then sends it to the DSP at least four days prior to the admission. The form is then scrutinised and the DSP sends the authorisation/regret/additional information letter to the hospital. Authorisation letter sent to the hospital will indicate the total amount that will be paid to the hospital as the per the benefits payable under the policy.

Emergency hospitalisation

In an emergency hospitalisation, like in the case of an accident or sudden heart attack, the policy holder needs to show his health card, which he receives when his policy starts. They need to fill up the pre-authorisation form and hand over the same to the attending doctor. The hospital then sends it to DSP/TPA within four hours of admission. The DSP then scrutinises the form and sends the authorisation back to the hospital.

Some leading life insurance companies providing health insurance also send an SMS alert to the policy holder if the form is authorised, to speed up the processes. There are some points that a policy holder should always remember while going for cashless hospitalisation:

The policy holder should always carry a valid photo ID with him at the time of admission.

At the time of discharge, check for the correctness of the bills, sign the claimant statement form.

If the total bill is more than the authorised amount, the insured has to settle the remaining amount before leaving the hospital; if the total bill is less than authorised amount, the difference is paid to the policy holder after the scrutiny of bills.

By incurring a small expenditure by way of annual premiums, which are reasonable, you are not only securing your health but also financial well-being.

It is time to take a holistic view of insurance. Insurance is not only about securing our life and material possessions but also about securing health. After all, health is wealth.

(The author is Senior Vice-President and Head — Customer Service and Operations, ICICI Prudential Life Insurance Co. Ltd.)

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