Health Insurance

Today, most Health Insurance policies do offer cashless hospitalisation facility and route your policy through a Third party Administrator (TPA). However you should be familiar with the terms- Network Hospital and Non-network Hospital.

Network Hospitals are those hospitals that your TPA has an agreement with. In case of hospitalisation, if you get admitted to a Network Hospital you will be eligible for cashless hospitalisation, subject to the other terms and conditions mentioned in your policy being fulfilled. In case you are admitted to a Non-network Hospital, you will have to settle the bills directly to the hospital and then seek re-imbursement through your TPA.

First, you need to be clear that there is no free treatment. It is just that, in the case of a cashless hospitalisation, the insurance company will bear the cost of treatment either fully or partially on your behalf.

Cashless hospitalisation is a facility provided by most health insurance policies and enables an insured customer to obtain admission and undergo the required treatment without a direct payment. The assigned TPA will mediate between the healthcare service provider (hospital) and the insurance company and settle the bills on behalf of the insured customer.

However it is important to understand the role of a hospital in cashless hospitalisation. The hospital is only a facilitator and has no authority to approve or disapprove any request for cashless hospitalisation. Certain protocols laid down by the Insurance Regulatory and Development Authority (IRDA) with respect to cashless hospitalisation will need to be adhered to strictly.

Hospitalisation happens under two circumstances - Planned and Emergency. Pre-authorisation of the estimated hospital expense is a must to avail this facility.

Planned Hospitalisation : In the case of a planned admission, you would have first consulted a doctor who in turn would have advised you on the probable date of hospitalisation. In such a case, you must have applied for an approval of the estimated hospital expenses directly with your TPA at least 4-5 days prior to the date of hospitalisation.

In case you have not applied for a pre-authorisation sufficiently in advance or if the doctor treating you advises you to get hospitalised immediately after the consultation, our Corporate Help Desk will assist you through the pre-authorisation procedure.

However, you will need to bear in mind that the Corporate Help Desk is only a facilitator and can in no way influence the decision on the approval. The approval can be turned down.

The pre-authorisation procedure is detailed below :

Step 1 : Establish contact with the Corporate Help Desk at the Hospital

Step 2 : At the Corporate Help Desk, you need to present the original health Insurance card issued to you by your TPA

Step 3 : Collect the pre-authorisation will forms pertaining to your TPA

Step 4 : Your pre-authorisation will have two sections -

1. General details on the health Insurance policy - to be filled in by you (the Corporate desk will assist you in case you have any difficulty)
2. Pertains to the treatment recommended for you-needs to be filled in and duly signed by the Doctor who is treating you (do not attempt to fill this section, contact the Corporate desk in case of any difficulty)

Step 5 : Return the completed form to the Corporate Help Desk. The personnel at the desk will verify the form for its completeness and let you know in case of any discrepancy

Step 6 : Once the form is complete in all respects, the Corporate Help Desk will fax the form to the office of your TPA.

Step 7 : The Corporate Help Desk will revert to you on the approval status

Emergency Hospitalisation : In case of emergency hospitalisation, the corporate help desk will take up your case on a fast track basis with your TPA and is likely to receive approvals within 3 hours during any working day.

For cashless treatment it is mandatory for the hospital to have an approval from your TPA. In case of delay in receiving the approval or when you cannot wait for receiving the approval owing to medical urgency you can undertake the treatment by paying the necessary cash deposit.

If you receive approval from your TPA after paying the cash deposit, you are entitled for refund of the cash deposit.

Cashless hospitalisation is linked to the approval of the estimated expenditure on your proposed treatment. In case you do not get your approval you will need to bear the entire expenditure incurred on the treatment. Therefore it is always prudent to get the approval and then get yourself admitted. You could explain the benefits of getting the approval before the date of your admission to your treating doctor as well when he recommends an immediate admission.

At M.G.M Hospital the Corporate Help Desk will not entertain any request for a refund of the amount paid if the approval comes after the process for your discharge has commenced.

Normally your request for approval might be rejected when :

1. Information contained in the pre-authorisation form is insufficient for the TPA to arrive at a decision and further information is not available for various reasons. However the chances of rejection under this criterion are rare since the Corporate Help Desk at the hospital is experienced in complying with pre-authorisation formalities and will advise you suitably
2. The ailment for which hospitalisation is being sought by you is not covered under your insurance policy for reasons like pre-existing ailment, specific exclusions (accident admission under the influence of alcohol)
3. You have exhausted your eligible Medical Insurance cover for the year.

In case your hospitalisation expenses exceed the pre-approved amount, you can approach the Corporate Help Desk to apply for an enhancement of the pre-approved amount. The Corporate Help Desk will apply for an enhancement on your behalf with the TPA and provide the necessary documentation. In case you have not exhausted your medical insurance limit, it is most likely that your TPA will approve the application for the enhancement - either for the requested enhanced amount or up to your insured limit after deducting the value already utilized by you during the year - whichever is less. If the TPA turns down the request for enhancement you will need to pay the amount incurred in excess of your approved amount directly to the hospital before the discharge.

For complete details on the medical expenses that are covered, and those that are not covered, you need to go through your health insurance policy. However, in general, the expenses listed below are not reimbursable under cashless hospitalisation

1. Registration / Admission Fee
2. Telephone Charges
3. Visitors / Attenders Charges
4. Ambulance Charges
5. Charges for Diet, which is not part of the administered treatment
6. Document Charges
7. Toiletries
8. Non-medical Expenses
9. Service Charges/ Surcharges
   

These need to be settled by you directly to the hospital at the time of discharge.

All the original documents including bills, lab reports, discharge summary and claim form. All the original documents duly signed by you need to be submitted to the hospital.

M.G.M New Bombay Hospital has a tie-up with several TPA's. (Current list is given below). However this is dynamic and will change from time to time. Kindly contact the Corporate Help Desk for an updated list.

1. Paramount Healthcare Pvt. Ltd
2. Dedicated Health Care
3. Bajaj Allianz General Insurance
4. Raksha TPA
5. E-Meditek Insurance
6. Cholamandalam General Insurance
7. Maharashtra Police Kutumb Aroyog Yojna
8. Medi Assist
9. Medicare TPA (Only Corporate)
10. Family Health Plan Ltd.
11. Vipul Med Corp
12. Med Save
13. TTK
14. United Health care