Is your Hospital Bill eating up your wallet?? A.Mohamed Ali. Mob#

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3 Is your Hospital Bill eating up your wallet?? 2

4 Are you a Satisfied Customer?? Health insurance in India has the most dissatisfied customers, and their loyalty levels are also declining as Insurance Companies fail to Match up to customer expectations. Tardy clearance of mediclaims, and inefficient cash-less facilities are just some of the drawbacks. 3

5 Health Insurance Policy Whether it is a new policy or a renewal policy Open and read the policy document to understand if it gives you the same cover you have been told at the time of signing the proposal form. Check whether your name/s, date/s of birth, policy issued date and renewal dates are correctly mentioned in your policy. 4

6 Do s and Don'ts for a Health Insurance Policy holder Please check if your Health card shows your name and date of birth without errors. Check for the Third party Administrator s name, address and contact details. Try to understand what are payable and what are not. Understand the first and second year exclusions too. Keep your policy document and the health card in a safe place at home that all your family members know. 5

7 Do s and Don'ts for a Health Insurance Policy holder Visit the insurance company s website and make note of the network hospitals in the places you live and /or you often visit. Note: Health Claims are available for any illness or surgery that requires a 24 hours of in patient hospitalization (there are certain treatments eligible for outpatient treatments). 6

8 The policyholders are in a clear advantageous position when they abide by the guidelines 7

9 Health Claims Health Claims are broadly classified into two types: 1.Cashless Hospitalization/Claims 2. Re-imbursement Claims 1.Cashless Hospitalization/Claims This is divided into Two Categories: a)planned Hospitalization: When a member of your family is to be admitted to the hospital for a surgery on a particular date, send a claim intimation to the Insurance Company through your third party administrator. This has to be done by the hospital concerned by filling up a Pre-hospitalization approval form along with the treating doctor s or surgeon s Diagnosis report and preliminary test reports that are required to make your claim. 8

10 Health Claims Planned Hospitalization (Contd ) Hospital should receive an approval within a day or two in the normal course. Remember - TPAs do not necessarily work on holidays Here you do not need to pay for anything (other than expenses for attendants food and accommodation). b) Emergency Hospitalization: After or during the admission the Hospital will send a request to Third Party Administrator for approval. Some hospitals may request you to pay a deposit prior to surgery and it will be paid back after they get their approval. If the approval is not received on time, call the Third Party administrator s office, give them the Card number, Hospital s name and patient s name etc and request them to speed up sending approval to the hospital. 9

11 Claims Procedure 2. Re-imbursement Claims: These claims are made if you opt for treatment in a nonnetwork hospital. Make sure that the hospital has a minimum number of 15 in patient beds which is the basic requirement to avail your health insurance claim. A claim intimation to the insurance company and insurance agent/advisor is always a must. Exclusions: Pre-existing illnesses/diseases. Certain major surgical procedures are not covered during the first year and the second year of the health insurance policy. Please try to now about them. 10

12 Call the One Who Really Cares Please do not forget to call your Insurance Agent/Consultant/ Advisor for help in processing the claim. He/she has to be Intimated prior to hospitalization. 11

13 Claims Procedure Keep all the original of bills, prescriptions, diagnosis reports, test reports safely. Request the insurance company to send you a claim form through courier. Fill in all columns and get this signed by doctor, surgeon in the hospital concerned. Affix hospital s rubber stamp on the claim form, all documents and bills to avoid any possible delays in claim processing. 12

14 Claims Procedure Make a summary of bills submitted. -Pre hospitalization expenses -Hospitalization expenses and -Post hospitalization expenses. Attach all original bills properly numbered matching with the summary, medical reports, discharge summary etc intact with the claim form. Make a set of copies of all the papers while submitting the claim form to the insurance company. 13

15 Claims Procedure (Contd ) Ask for an acknowledgement on the copy of your claim form while submitting the claim. If follow up treatment, medication is required, post hospitalization claim can be made later. If the claim is admissible you will get the reimbursement within 2 to 3 weeks time. Please keep your insurance consultant informed about your claim. Always consult your insurance advisor prior to under going surgeries. If cataract surgery is necessary for both eyes better have one eye taken care two months prior to the expiry of the policy and the other eye after the renewal date. 14

16 Your policy can be rejected for cashless authorization request if you have not verified with your TPA about your policy enrollment if in case you have a fresh policy / or recently got your policy renewed. 15

17 Do the Do s And Not the Don ts Do s Pre - authorization form from the Insurance helpdesk 3-4 days prior to the admission for planned hospitalization should be obtained. The treating doctor should fill the Pre - authorization form. Cashless treatment at the hospital can be availed after receipt of written authorization from TPA. Don'ts Admission at the hospital merely for investigation, evaluation or health check ups- will not be approved by TPAs. Do not insist on admission on cashless basis at the Hospital without obtaining the pre -authorization approval from TPA. Don't carry back any original document at the time of discharge from the hospital, if the TPA approves your cashless claim. 16

18 You Need Some One Who Takes Care of YOU Please do not buy Health Insurance Online, Direct from Insurance Company or through Banks/Cards. Because none is better in my Experience. You will have no one to take care of you at the time of Claims. Always have an intermediary to help you when required. 17

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21 I am available 24 x 7 x