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On the date of discharge, the hospital team has to send the final bill with break up and discharge summary to TPA After the receipt, within 2 hrs the enhancement (as per policy limits) will be processed after deducting the non-medical expenses (paid by the patient) and an approval letter will be sent to hospital fax or email.

Note: - Co-pay (if applicable) has to be paid by the policyholder Some of the Hospitals are Preferred Provide Network (PPN), Gipsa and Hospital tariff, if cashless is taken in those hospitals the final approval will be as per the respective tariff.

If it is a planned hospitalization then the pre-authorization request needs to be sent 48 hours from the date of admission. In case of emergency, the pre-authorisation request needs to be sent within 6 hours from the time of admission.

The policyholder needs to pay the non-medical expenses and the co-pay amount (if applicable). He will need to pay the difference amount (the difference between the final bill and the approved amount).

Medical expenses are: Admission fees, Registration fees, gloves, blade, water bed, food & beverages, extra bed etc., Policy holder needs to pay for these expenses which are not covered by insurance policy terms and conditions.

A minimum of 24 hours of hospitalization (if not day-care) with an active line of treatment is required. However, there are a few specific ailments /procedures specified in the policy which can be covered even though the period of hospitalization is less than 24 hours. Such as Dialysis, Chemotherapy, Radiotherapy, Eye Surgery etc.,

Rejection will be done as per the policy terms and coverage, below are a few examples of rejection.

1. If hospitalization is for observation & investigation purposes
2. If any particular aliment/disease/treatment is found not covered under policy terms and condition
3. If found that the treatment can be done under an OPD basis
4. If found that no active line of treatment is available
5. If Shortfall and the policyholder has not responded within the given TAT
6. If a policy is invalid
7. Rejection of cashless is not a denial of treatment. You may proceed with reimbursement claim submission.

In such a situation the policyholder will be liable to pay the difference amount. During Cashless TPA inform the hospital about the policyholder’s eligible amount and the hospital will recover the amount over and above the credit amount from the policyholder directly at the time of Discharge

Reimbursement Claim and Cashless Network Claim (for Hospital).

TPA will assess the validity of the claim based on the documents submitted, validate the policy, validate the treatment undergone and settle the claim within the claim settlement parameters. In case of claim does not adhere to parameters, the case would be rejected.

If Documents are not completed, then TPA will request the additional shortfall documents

Note: If any bills and receipts are not supported by valid documents, then the claimed amount of that bill will not be processed.

You should submit the entire set of ORIGINAL DOCUMENTs like

1. Claim form duly signed
2. TPA card (photocopy)
3. Identity Proof (photocopy)
4. Discharge summary with seal & signature of the hospital authority
5. In-patient bills
6. Doctor’s prescription
7. Pharmacy bills with breakups
8. Investigation reports like MRI, ECG, CT scan, and X-Ray etc
9. Laboratory reports
10. Paid receipt with hospital seal & signature
11. Cancelled cheque copy for claim payment.

Note: During processing, in case of any additional document TPA will raise a Shortfall query

Shortfall query documents are those which are not submitted by the claimant, which is mandatory for the further claim process.

The amount which is not approved is a disallowed amount such as Non-medical expenses, no proper bill break up, Lab report not submitted, aliment capping exceeds the Sum insured Etc.

Day Care surgeries are those which do not require 24 hours of hospitalization such as Cataract (Eye) surgery, Dialysis, Kidney stone removal, Chemotherapy, D&C etc.

Depending on Insurance policy some of the day care surgeries are payable according to terms and conditions.