FAQ on Cashless Hospitalisation

What is cashless hospitalisation?

Cashless hospitalisation is a health insurance option under which the insured individual can get admitted to a hospital and avail medical treatment without a direct payment of bills. The third party administrator (TPA) mediates between the healthcare service providers (hospital) and the insurance company and settles the bills on behalf of the insured customer. Please note that customers can avail cashless hospitalisation only in hospitals that are part of their TPA’s network.

However, one must bear in mind that the role of a hospital in the process is only that of a facilitator. A hospital has no authority to approve or disapprove requests for this facility and the sole power for the same lies with the TPA. The Insurance Regulatory and Development Authority (IRDA) have laid down certain norms and protocols for cashless hospitalisation that have to be strictly followed.

What is the procedure for cashless treatment at BMH?

To avail cashless hospitalisation facility at Baby Memorial Hospital, the estimated amount needs to be pre-authorised by the TPA. Hospitalisation of a patient can be divided into two categories — planned and emergency.

Cashless Treatment for Planned Hospitalisation

A planned hospitalisation is one in which the patient gets admitted on the date advised by a doctor working in the hospital. In this case, you have to apply for the approval of estimated medical expenses to your TPA at least 4-5 days before the date of hospitalisation.

In case you fail to apply for the pre-authorisation or if the doctor you consult advises immediate hospitalisation, please consult the Insurance Desk at BMH. They will guide you through the pre - authorisation procedure. However, you need to remember that the Insurance Desk is only a facilitator and cannot influence the approval of the application by the TPA, and the approval can be turned down.

What is the pre-authorisation procedure?

Approach the Insurance Desk at BMH located near the Emergency Department at Block B in the ground floor.

Please show the Insurance Desk the original Health Insurance Card issued by your TPA and submit a photocopy of ID proof issued by the government (PAN card/Driving Licence/Voter ID card etc). In case of corporate group insurance policy, please produce the photocopy of employee ID card.

Collect the pre-authorisation forms pertaining to your TPA.

The pre-authorisation form has two sections:

• Details on health insurance policy, which is to be filled in by you. Please seek the Insurance Desk’s help in case of any doubt.
• The second section pertains to the treatment for which insurance is sought. This part needs to be filled in and signed by the doctor treating you. Please do not fill this section yourself.

Once the form has been filled and signed, return it to the Insurance Desk. The personnel at the desk will verify if the form is complete and let you know in case of discrepancies.

The Insurance Desk will fax the completed form to your TPA’s office for approval.

The desk will revert to you on the approval status. Please enquire with the desk on the same.

Cashless treatment of emergency hospitalisation

In case of emergency hospitalisation, the Insurance Desk will expedite the process. The desk will take up your case with the TPA on a fast track basis and is likely to receive a reply on approval within three hours during a working day.

For cashless treatment to be availed, it is mandatory that the hospital gets an approval from your TPA. In case there is a delay in receiving approval or if the medical urgency is immediate and cannot wait for approval, treatment can be availed by paying the necessary cash. After paying the cash, if the TPA approves your request, the amount will be refund to you.

What if I don’t get approval during time of discharge from hospital?

Availability of cashless hospitalisation facility is subject to approval of the estimated expenditure on proposed treatment. In case approval has not been received for the same, you will need to directly pay the entire expense incurred on treatment. Hence, it is advisable to plan ahead and get your TPA’s approval before getting admitted to the hospital. In case your doctor recommends an immediate admission, discuss with him/her if it can wait till you get approval and apply for the same immediately.

Can cashless hospitalisation be rejected?

Yes. Requests for cashless hospitalisation are rejected by the TPA under the following circumstances:

The ailment or treatment for which the facility is being sought is not covered under the insurance policy under clause such as pre-existing ailment and specific exclusions (eg: road traffic accident under the influence of Alcohol).

The TPA finds the information given in the pre-authorisation form insufficient for approval and seeks more documents. But, chances of rejection due to this condition are minimal, as BMH’s Corporate Help Desk is well versed with the pre-authorisation procedures and will advise you if anything is found wanting.

The patient has already used up the eligible medical insurance cover for the year.

What if the medical bills overshoot the approved amount?

In case the actual medical expenses incurred exceed the amount approved by your TPA, you can approach the Insurance Desk to apply for enhancement of pre-approved amount. On your behalf, the Insurance Desk will apply for an enhancement to the TPA and provide the necessary documentation.

If your medical insurance limit has not been exhausted, it is most likely that your TPA will approve the application either for the requested amount or up till the insured limit for the year after the amount already utilised is deducted, whichever is less. However, if your TPA turns down the request for enhancement application, you will have to pay the amount that exceeds your approved amount directly to the hospital before being discharged.

Does cashless hospitalisation cover all hospital expenses?

Medical services covered during cashless hospitalisation vary from policy to policy, so for exact details on medical expenses covered and those excluded you need to refer your health insurance policy. However, in most cases, the expenses listed below are excluded from cashless hospitalisation.

• Registration / Admission Fee
• Telephone charges
• Visitors / Attenders charges
• Ambulance charges
• Charges for diet, which is not part of the treatment
• Document charges
• Toiletries
• Non-medical expenses
• Service charges

So even if cashless hospitalisation is approved, these expenses need to be paid by you directly to the hospital while the patient is discharged.

For cashless treatment, what documents must be submitted at the time of discharge?

All original documents including bills, lab reports, discharge summary and claim form signed by you must be submitted to BMH before you leave the hospital.

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