Taking Cover . Know your network hospitals

With the constant rise in cost of healthcare in India, making the mistake of not buying a health insurance can prove to be disastrous. A comprehensive health insurance cover not only helps you easily afford quality healthcare but also gives you access to a plethora of cashless benefits that you may enjoy under a health plan.

One of the most celebrated features of the cashless benefit in a health insurance policy is the freedom to get treated in any network hospital. This means that an individual who is insured under a comprehensive health insurance policy can claim the required medical treatment without having to pay any amount at the hospital.

The concept

When you buy a health insurance policy, the insurance company gives you a list of network hospitals that it has a tie-up with. These hospitals provide the insured with the various benefits of cashless hospitalisation. Under such plans, the health insurer directly settles all the hospital bills without taking any charges from the insured except the file charges. For example, Religare Health Insurance has 4,987 network hospitals; Star Health has 8,341; Max Bupa 4,115; Apollo Munich 4,721; and HDFC ERGO has 6,402. Network hospitals ensure hassle-free, cashless treatment.

While taking treatment under a health insurance plan, there are majorly three entities involved — the network hospital, the insurer/third-party administrator (TPA - who acts on behalf of the health insurer) and the insured individual.

You can avail yourself of the services of cashless health insurance under two circumstances — planned as well as unplanned hospitalisation (emergency). Under planned hospitalisation, the insured is well aware about the treatment process and books a bed in the hospital prior to taking treatment at any of the network hospitals.

To get admitted, the insured would first need to show the company-issued health insurance policy for verification purpose and further fill the pre-authorisation form. The pre-authorisation form can be easily downloaded from the insurer’s website or will be available at the hospital’s TPA counter. Every hospital has a dedicated TPA counter or kiosk where all the insurance-related queries and processes of the insurers are addressed.

Once you submit the filled form at the TPA counter, a designated person verifies it and informs the concerned insurer. If need be, the TPA might ask you to inform the insurer about the hospitalisation and the claim. The insurer/TPA further processes the form and takes required action. and has the right to approve or turn down the claim request, depending on the case and the required formalities.

Upon acceptance of the claim, the insurer/TPA sends an authorisation letter to the hospital, stating the amount approved for the treatment. This amount is directly paid to the hospital by the insurance provider. The approximate turn-around time (TAT) for pre-authorised claims in case of network hospitals is about 30 minutes to two hours. However, one must know that TAT completely varies from insurer to insurer.

As a policyholder, be aware of the fact that even a cashless facility can be denied in a network hospital. This may happen due to insufficient information being sent to the insurer by the policyholder or the hospital. Also, if any of the illnesses is not covered by the insurer for which the insured is seeking treatment or if the request for pre-authorisation is not sent in time, the insurer can deny the claim.

The writer is Business Head, Health Insurance, Policybazaar.com

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