Health Insurance

Cashless hospitalization is a health insurance option where the insured individual can get admitted to a hospital and receive medical treatment without directly paying the bills. The third-party administrator (TPA) acts as an intermediary between the healthcare service provider (hospital) and the insurance company, settling the bills on behalf of the insured customer. This facility is available only in hospitals that are part of the TPA’s network.

It’s important to note that the hospital’s role in this process is solely that of a facilitator. The hospital does not have the authority to approve or reject requests for cashless hospitalization; this decision is solely in the hands of the TPA. The Insurance Regulatory and Development Authority (IRDA) has established specific norms and protocols for cashless hospitalization that must be strictly adhered to.

To avail of the cashless hospitalization facility at RAYHAN EYE HOSPITAL AND LASIK CENTRE, the estimated amount needs to be pre-authorized by the TPA. Hospitalization can be divided into two categories — Planned and Emergency.

Cashless Treatment for Planned Hospitalisation: Planned hospitalization occurs when a patient is admitted on a date advised by a doctor. In this case, you must apply for the approval of estimated medical expenses from your TPA at least 4-5 days before the hospitalization date. If you fail to apply for pre-authorization or if immediate hospitalization is advised, consult the Insurance Desk at RAYHAN EYE HOSPITAL AND LASIK CENTRE. They will guide you through the pre-authorization procedure. However, note that the Insurance Desk is only a facilitator and cannot influence the TPA’s decision, which could be denied.

What is the pre-authorisation procedure?

1. Approach the Insurance Desk at RAYHAN EYE HOSPITAL AND LASIK CENTRE, located on the ground floor, Room No. _____.
2. Show the Insurance Desk the original Health Insurance Card issued by your TPA and submit a photocopy of a government-issued ID (PAN card, Driving License, Voter ID, etc.). For corporate group insurance policies, provide a photocopy of the employee ID card.
3. Collect the pre-authorization forms for your TPA.

The pre-authorization form has two sections:

• Details on the health insurance policy: To be filled in by you. Seek assistance from the Insurance Desk if needed.
• Treatment details: This section must be filled in and signed by the treating doctor. Do not fill this section yourself.

After completing and signing the form, return it to the Insurance Desk. They will verify its completeness and address any discrepancies. The desk will then fax the completed form to your TPA’s office for approval. Follow up with the desk on the approval status.

Cashless Treatment for Emergency Hospitalisation: In case of emergency hospitalization, the Insurance Desk will expedite the process. They will handle your case with the TPA on a fast-track basis, with approval usually received within three hours during working hours.

For cashless treatment, the hospital must receive approval from your TPA. If there is a delay or the medical urgency is immediate, treatment can proceed with upfront cash payment. If the TPA later approves the request, the amount will be refunded to you.

What if I don’t get approval at the time of discharge? Cashless hospitalization is subject to TPA approval of the estimated treatment costs. If approval is not received, you will need to pay the entire expense directly. It’s advisable to secure TPA approval before hospital admission. If immediate admission is required, discuss with your doctor whether it can wait until approval is obtained and apply for it promptly.

3. Can cashless hospitalisation be rejected? Yes, cashless hospitalization requests can be rejected by the TPA under the following circumstances:

• The ailment or treatment is not covered under the insurance policy due to exclusions (e.g., pre-existing conditions, alcohol-related incidents).
• The TPA requires more information from the pre-authorization form, though this is rare as our Corporate Help Desk is well-versed in the procedures.
• The patient has exhausted their medical insurance cover for the year.

4. What if the medical bills exceed the approved amount? If actual medical expenses exceed the approved amount, approach the Insurance Desk to request an enhancement. The Insurance Desk will submit the necessary documentation to the TPA. If your insurance limit has not been exhausted, the TPA may approve the additional amount. If the TPA denies the enhancement, you will need to pay the excess amount before discharge.

5. Does cashless hospitalisation cover all hospital expenses? Medical services covered during cashless hospitalization vary by policy. Refer to your health insurance policy for exact details. Typically, the following expenses are excluded from cashless hospitalization:

• Registration/Admission Fee
• Telephone charges
• Visitor/Attender charges
• Ambulance charges
• Non-treatment-related diet charges
• Document charges
• Toiletries
• Non-medical expenses
• Service charges

Even if cashless hospitalization is approved, these expenses must be paid directly to the hospital at discharge.

6. What documents must be submitted at discharge for cashless treatment? Submit all original documents, including bills, lab reports, discharge summaries, and the claim form signed by you, to RAYHAN EYE HOSPITAL AND LASIK CENTRE before leaving the hospital.