Health Insurance is an essential part of financial planning as it provides financial protection against medical expenses. Cashless facility allows patients/policy holders to obtain medical treatment without direct payment at Network hospitals, it eases financial burden of medical treatment for patients/policyholders.
In Cashless facility, Hospitalization happens as planned and Emergency:
➢ Planned hospitalization: Where you have been diagnosed before and advised a surgery by consultants on Zen hospital panel
➢ Note:- Prior Approval is always Mandatory in Planned hospitalization, in planned admission, estimated bill amount will vary depend upon Room category opted by patient, Patient should be aware when selecting room category as estimate will vary according to room category, and should discuss potential expenses with Consultant.
➢ Emergency Hospitalization:
You must approach TPA department with 24 hours of admission with all necessary documents after you are advised Emergency admission.
You need to submit following documents for pre- approval process:
1. Health insurance policy copy, (Must for individual policy holders). E-card if corporate policy holder.
2. Patient’s Aadhar Card, Pan Card.
3. Admission Note given by your treating doctor.
All necessary investigations reports (in case of planned hospitallization). Your TPA will respond in following ways:
1. Query
2. Initial/Partial Approval
3. Denial of your claim (with reason or no reason)
➢ As per your health policy Terms & Condition, The patient is eligible for specific class of accommodation (usually 1% of sum assured), if the patient desire to avail higher class / Treatment which are not covered under the policy, the patient will have to pay the proportionate difference to the hospital before the discharge.
➢ You will be asked to pay a refundable security deposit during hospitalization whether planned or emergency, which will be refunded after claim settlement.
➢ In case of planned Hospitalization, deposit amount will depend upon estimated cost/bill.
However it is important to know, the hospital is only a FACILITATOR and has no authority to approve or disapprove any request for cashless hospitalization. Certain protocols laid down by the Insurance Regulatory and Development Authority (IRDA) with respect to cashless hospitalization will need to be adhered strictly.
At the time of Discharge, final bill, discharge summary and any other document required will be sent to TPA for Final approval. This process might take 4-6 hours once the documents are forwarded to TPA.
In case if TPA denies requested enhancement/bill, you will have to pay the entire Hospital bill, by cash/ credit card/online payment, prior to being discharge from the Hospital. You must note cashless hospitalization may not cover Nonmedical expenses.
Patient are requested to make the cash payment for Non-admissible items- E.g. GLOVES/BLADE/CAP Etc. (List will be available on request at TPA dept.) if any amount towards the cashless hospitalization is deducted part/ full while settling the claim by your insurance co. / TPA, the same will have to be borne by the patient, it includes deductibles, co-payments, and any expenses that are not covered by their policy. it is important to note patients are responsible for paying all costs not covered by their insurance policy. in the event of cashless request remains under process, patient shall pay 80% of the procedure fees as advance during the admission. Once the hospital received the full approval from the insurance co. / TPA, the hospital will refund the advance paid amount keeping security deposit within 3 working days of patient getting discharged.
In case of Reimbursement, you need to submit the required documents, bills along with Claim form A and B to concerne TPA office, which you can get from online website as per policy.
