Claims

Claims Management

Role of Third Party Administrators (TPA)

Major players on claim servicing side are in-house teams of few private insurers & TPA’s. TPAs play an important role in delivering cashless service. TPA is a service organization under contract from insurance company to administer its health insurance policies. TPA performs the role of service integrator – a triage between the insurer, the policyholder and the hospital / Nursing home etc.

TPAs are regulated by IRDAI for the purpose of licensing and functioning in health insurance space. IRDAI periodically revises these guidelines and depending upon the need of the market, guidelines are amended from time to time.

Identification

Remember to carry the followings:

1. TPA Health card or Policy copy
2. Valid Photo ID proof

The claim procedure varies for cashless claim & reimbursement claim

Cashless Claims
The patient or policyholder is not required to pay the hospital bill as TPA / Insurance company will settle the bill with the hospital directly. Charges not covered by the insurance policy are required to be paid by the client.

Cashless facility will be given only on verification of your coverage. Once the hospital receives authorization from TPA / insurance company, your cashless treatment will begin at the hospital. Cashless facility is only for network hospital, so the patient before admission must check if the hospital falls in cashless network or not. If yes, the following procedure should be followed:

Report and Claim

Please contact to the concerned TPA as mentioned on the policy copy to report a claim as per the procedure given below:

Procedure A: For Cashless Claims

Reason for Denial of cashless claim

Cashless claim may be rejected for variety of reasons. Lack of documents or hospital not falling in network, incomplete patient information, information sent in sufficient, aliment not covered under the policy, medical record/history not available, services excluded or not covered, waiting period are the primary reasons for denial of cashless claim. In such cases, the hospital expenses are be borne by the policy holder & then file a claim with Insurance company/TPA for reimbursement of expenses.

Get admitted in any hospital falling within the definition of hospital defined in policy

Send medical intimation to TPA/Insurance company within 24 hrs of hospitalization mentioning policy no. & health card details

After treatment, settle your hospital bill & get discharged

After discharge send the following documents to TPA/Insurance company within a week:

  1. Signed claim form
  2. Hospital bill & receipts
  3. One stop market
  4. All investigation reports
  5. All prescription, discharge card, billing
  6. Details of pre hospitalization expenses, if any claim form may be downloaded for
  7. Insurance company/TPA will settle your claim & pay you the admissible amount through Cheque /DD / Online transfer

Procedure B: For Reimbursement Claim

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