Most of us do not visit a hospital by choice. We do go through emotional troubles during our visit to a hospital if somebody we love needs medical help. The last thing one needs at that time is to run around to arrange for the finances that come with the treatment. Medical Insurance is only thing that can take some of the pain away.

A Mediclaim policy offers coverage for expenses incurred by a person during hospitalization. The policy may offer 2 kinds of facilities: Cashless and Reimbursement claim

A Third-Party Administrator TPA is licensed by Insurance Regulatory (IRDAI) to process insurance claims under the Mediclaim policy. TPA is an intermediary between the Insurance company and Policy holder. A TPA can approve of a cashless claim settlement especially in case of planned hospitalization or reimburse it later.

If you are covered in the list of Insurance companies for medical services, SK Hospital will assist you getting the claim processed by your Insurance company or Third-Party Administrator (TPA)

List of Insurance companies

SK hospital has tied up with the following institutions/ insurance companies and TPAs for your convenience

Planned Hospitalization

A doctor when providing a treatment plan will suggest a tentative date of hospitalization. In such a case an approval of estimated hospital expenses can be taken up with the insurance company/TPA, prior to the date of hospitalization.

In cases where a doctor advises on immediate hospitalization after consultation the Insurance cell at the hospital can assist through the pre-authorization procedure.
Note: The Insurance cell is only a facilitator and cannot influence the decision on the approval

Pre-authorization procedure

The typical steps during pre-authorization are listed here

• Contact Insurance cell at the hospital before or during the time of admission.
• Produce original health Insurance card issued by insurance company/TPA with photocopy of ID proof (PAN card/Driving License etc/Voter ID etc), Aadhar, consultation, previous treatment details, Photocopy of employee ID card for corporate group insurance policy.
• Pre-authorization form has two sections. Details of the insurance policy to be filled by patient, treatment recommended to be filled in by the doctor (You can contact the insurance cell in case of difficulty)
• The insurance cell will e-mail the completed form to the office of the insurance company/TPA or upload in the respective insurance portal.
• The insurance cell will revert to the patient/applicant on the approval status.

Emergency Hospitalization

The insurance cell will take up the case on a fast-track basis with insurance company/TPA to receive approvals within 3 hours during a working day in case of emergency hospitalization. In case of delay in approval and due to the medical emergency treatment can be availed by paying the necessary cash deposit. Refund of the cash deposit is made once the insurance company/TPA approves the claim.
It is always safe to first get the approval before hospitalization.

Approval rejection

The request for approval could be rejected due to the following reasons

• The treatment for which hospitalization is sought is not covered under the insurance policy.
• Road traffic accident and other diseases derived out of prolonged alcohol usage under the influence of alcohol
• Insufficient information in the pre-authorization form (Such chances are rare because the Hospital insurance cell is experienced in complying with pre-authorization formalities and will advise you suitably)
• Medical insurance cover for the year has been exhausted.
• If there is maturity exclusion in the policy or policy waiting period exclusions.

Enhancement of Pre-approved amount

The insurance cell will apply for an enhancement in case the hospital expenses exceed the pre-approved amount. If the insurance company/TPA does not approve the new amount the patient will have to pay the excess amount by sending interim bill and treatment summary+.

Expense not covered under Insurance

There are some expenses that may typically not be reimbursable. These are:

• Registration / Admission Fee
• Telephone Charges
• Visitors / Attenders Charges
• Charges for Diet, which is not part of the administered treatment
• Document Charges
• Toiletries
• Non-medical Expenses
• Service Charges
• Ambulance charged
• On call charges

Discharge Process and Insurance settlement:

The discharge process takes between 6 to 8 hours for a person who has medical insurance. The claims settlement process depends on the administrative efficiency of the hospital and insurer. A proactive approach by the patient/bystander could speed up the settlement and hence shorten the hospital discharge time considerably.

A few things that can be done to speed up the process are:

• Check with the doctor for a probable date & time of discharge
• Inform the insurance help desk in the hospital and ask them to prepare the relevant documents
• Be in touch with the Insurance company/TPA to check status