Jehangir Hospital | Hospital | Cardiology Hospital | Heart Surgery

Cashless Insurance Logistics For Patients and Relatives

Cashless


		Cashless’ applies only to

		the admissible expenses component of your bill and that amount which, is covered by your individual policy.

		The inadmissible component of your bill will have to be settled by you in cash, as and when required by the hospital.

		Until your designated TPA pre-authorizes your admission you are not eligible for cashless admission. Should you insist on getting admitted before the pre-auth approval, it is entirely at your own risk. The admission will be considered as a routine ‘cash’ admission and you will be required to pay a deposit as well as make payments in cash until your TPA clears the admission as ‘cashless’.

		STEP-1

	1	If you have a cashless insurance policy, please collect the Insurance Pre-authorization form from the Corporate Help Desk (at main reception) and take it to your consultant for filling up the technical details. Thereafter return it to the Help Desk for them to complete the required documentation procedures.

	2	It is essential that you or a close family member fills up the form, in order to avoid any discrepancy or doubt. Incomplete / incorrect forms may be rejected / require further clarification that simply delays the admission process.

		IN AN EMERGENCY..

		Please help the CMO in filling the pre-authorization form at the earliest so that the process of insurance authorization, from the TPA, is initiated without delay.
		The Hospital will provide basic emergency treatment without waiting for approval but where expensive pharmacy items are anticipated, eg stents and implants, for specialized procedures, the hospital retains the right to ask for deposit to cover this anticipated cost, until the TPA confirms that the insurance policy is valid and indicates the limit of coverage.

		DO NOT WITHHOLD FACTS OR GIVE INCORRECT FACTS.

		Non-declaration of material facts can lead to discrepancies and subsequent rejection of the claim after discharge , EVEN IF Pre-authorization approval is granted .
	1	Please note that pre-authorization approval to commence treatment is given on basis of the information provided by you and the doctor before admission. However, the final approval of claim is based on material facts as mentioned in the discharge summary or in your case papers.

	2	In many cases the patient is admitted by friends/ colleagues who are unaware of the patient’s medical history. In such cases the initial history does not tally with the history correctly given subsequently by the patient / relatives while being treated in the ward. Such discrepancies are noted by the TPA when they audit the documents at discharge and may result in rejection of claim or delay in processing.

		OBTAINING PRE-AUTH BEFORE ADMISSION
		For elective cases, clearance from TPA normally takes anywhere between 24 to 48 hours. The
		patient HAS to wait until the authorization is obtained before cashless admission can be granted.

		If the patient wishes to get admitted before clearance is given by the TPA, cash deposits will have to
		be paid to the hospital as the admission will be considered a cash admission until pre-auth approval is received from the TPA.

		PRE-OP INVESTIGATIONS ON OPD BASIS
		Cashless policy does not cover pre-op investigations and if these are done post admission they ll
		willbe denied.
		However, the policy does allow for a subsequent reimbursement of the bill for the pre-op expenses
		incurred.
		Patient has to pay to the hospital and file for reimbursement through the TPA / agent.

		Cap on Entitlement
		Most policies have a cap on the room rent. Please discuss with the Corporate Help Desk for
		Desk for information on your eligibility.
		For eg, you may have a coverage of 2.0 lacs. However, if your policy stipulates that your entitlement is room rent equivalent to 1% of the coverage you are entitled to stay in a room not costing over Rs 2,000/- per day (1% of 2.0 lacs).
		If you stay in a higher category room you will end up paying the difference between the categories from your pocket, even if the bill is less than 2 lacs.

		CASHLESS ONLY FOR ACTIVE LINE OF TREATMENT.
		As per IRDA norms “ Admissions primarily for investigation and evaluation and oral medications are
		not payable.”

		Patients getting admitted for expensive investigations like MRI, etc will end up paying for the scan as well as all other hospitalization expenses.

		It therefore makes sense to get the investigations done on OPD basis with the patient paying cash and getting it reimbursed later, if admission is required.

		Investigations related to the specified ailment, done within 30 days prior to admission and 60 days after discharge are eligible for reimbursement in most policies.

		Day Care Procedures Eligible For Cashless

		Dialysis, chemotherapy, radiotherapy ,eye surgery, kidney stone removal, tonsillectomy D&C, Angiography are day care procedures accepted for cashless treatment.

		For all other admissions the patient must stay a minimum of 24 hours in the hospital. Else the claim will be denied.

		Discharge Process
		Depending upon your TPA, this process may take from 6 to 24 hrs and the time taken is not in our hands. During this time the patient must be physically present in the hospital. If the TPA team carry out a check to see whether patient is in the hospital and find him / her missing, the claim will be denied.