GLOSSARY

Given below are a few frequently used terms pertaining to medical insurance that you need to be familiar with.

• Cashless Access : A special benefit extended by an insurer or by the assigned TPA for availing medical treatment as an inpatient without the necessicity to pay the treatment costs up front to the hospital. Under this procedure the payment due to the hospital will be met out either by the insurer or by the assigned TPA. After the discharge from the hospital the bills pertaining to medical expenses incurred at the hospital, are sent to the Insurer /TPA, (subject to insurance policy and conditions) for reimbursement by the hospital. The hospital can claim in accordance to the preauthorized limit and additional cost as envisaged by the enhancement. In any case the upper limit of this facility cannot exceed the sum insured under the contract of insurance.


• Denial : Repudiation of a Pre Authorisation request /Admission liability/cashless facility and or settlement of a claim under the insurance contract.


• Discrepancies: Any difference between the amount claimed and admissible amount and also any violation of terms & conditions of the insurance policy or agreement.


• Domiciliary Hospitalisation: Medical treatment for period exceeding 3 days for such illness/diseases/injury which in the normal course would require care and treatment at a hospital but is actually taken whilst confined at home under certain circumstances (where the patient cannot be moved to the hospital or due to lack of accommodation – as per the definition of insurance policy)


• Enhancement: Situation when insurer seeks to increase the limit of the authorized claim amount resulting from extension of hospitalisation.

• Exclusions: The items that are specifically and expressly removed from the scope of the insurance contract and hence are not payable.


• Hospitalisation: Medical treatment after getting admitted in a hospital.


• Insured Amount: The maximum limit up to which the insured can seek medical treatment under that mediclaim policy.


• Insured/Policy Holder: Individual who by paying a premium, secures himself to receive medical treatment up to a fixed sum of money in the even of injury, loss or damage to his body.


• Insurer: A corporate body licensed by IRDA for underwriting various insurable risks against any or all insurable perils with an assurance to make good the loss in an unforeseen eventuality.


• IRDA: Insurance Regulatory & Development Authority, a body constituted under the Ministry of Finance to deal with licensing, regulating and monitoring all activities relating to the insurers, brokers, agents, corporate agents and the TPA's.


• Limitations: Restrictions in the operative clause of the insurance contract to the limit of benefits, use etc…


• Mediclaim Card: A card issued by your TPA with a primary purpose of identification. This contains the policy number, name and validity period. Many of the TPA's prefer to place insured's photograph & signature to improve its authenticity. Though it is being popularized as a cashless card, it serves only as a means to avail cashless benefit subject to the terms & conditions of the policy.


• Mediclaim Policy: A insurance policy that covers hospitalisation expenses incurred during an inpatient hospitalisation. Please check terms an conditions of the policy to understand the nature and the scope of risk covered.


• Medico Legal Case: A situation arising out of treatment at the hospital for any bodily injuries sustained in an accident or an attempt of suicide, which needs to be intimated to the police and other concerned authorities for any
investigation and procedures. (Burns, Suicide, RTA, Assault)


• Network Hospital: An hospital which has entered into an agreement / MOU with an insurer or a TPA to request preauthorization, extend cashless facility and accept payment at a later date on submission of bill complying to the policy requirements. Those hospitals who do not have a prior agreement for cashless hospitalisation with your insurer / TPA are called non-network hospitals.


• Planned Hospitalisation: Taking Advantage of the medical condition where one does not require immediate hospitalisation (as it would not effect his quality of life in any way), the insured seeks preauthorization sufficiently in advance of actual admission in the hospital for treatment on cashless basis.


• Policy Terms & Conditions: Terms and conditions outlining the details and the limitations of the insurance contract indicating the requirements for fulfilling or adhering to the contract of the insurance.


• Pre-Authorization: Authorisation issued by the insurer or by the assigned TPA for admission and treatment up to a value as deemed fit by the insurer, for treatment by the hospital. To receive preauthorization one has to make a request providing the details contained in the Pre-Authorisation Form.

• Query: Clarification requested to dispel any doubt pertaining to the line of treatment and the contract of insurance.


• Reimbursement: A facility under which the insured can claim the expenses borne by him during hospitalisation which is otherwise claimable under his insurance contract.

• Toll Free Number: A telephone number (calls to which are not charged) provided by your insurer/TPA to get in touch with them for any clarification.


• TPA: A corporate body licensed by IRDA for processing and setting on their behalf, claims arising under medical insurance policies and to coordinate with hospitals for all relevant and related processes.


This information collated by B. M. Birla Heart Research Centre is presented for public knowledge. It should in no way be construed as legally binding on B. M. Birla Heart Research Centre.

Do all Health Insurance Policies offer cashless hospitalisation facility?

Today, most Health Insurance policies do offer cashless hospitalisation facility and route your policy through a Third party Administrator (TPA). However you should be familiar with the terms- Network Hospital and Non-network Hospital.

Network Hospitals are those hospitals that your TPA has an agreement with. In case of hospitalisation, if you get admitted to a Network Hospital you will be eligible for cashless hospitalisation, subject to the other terms and conditions mentioned in your policy being fulfilled. In case you are admitted to a Non-network Hospital, you will have to settle the bills directly to the hospital and then seek re-imbursement through your TPA.

Does cashless hospitalisation mean I can just walk into a hospital and get admitted for treatment free of cost?

First, you need to be clear that there is no free treatment. It is just that, in the case of a cashless hospitalisation, the insurance company will bear the cost of treatment either fully or partially on your behalf.

Cashless hospitalisation is a facility provided by most health insurance policies and enables an insured customer to obtain admission and undergo the required treatment without a direct payment. The assigned TPA will mediate between the healthcare service provider (hospital) and the insurance company and settle the bills on behalf of the insured customer.

However it is important to understand the role of a hospital in cashless hospitalisation. The hospital is only a facilitator and has no authority to approve or disapprove any request for cashless hospitalisation. Certain protocols laid down by the Insurance Regulatory and Development Authority (IRDA) with respect to cashless hospitalisation will need to be adhered to strictly.

What procedures should I follow to avail the facility of cashless hospitalisation at B. M. Birla Heart Research Centre ?

Hospitalisation happens under two circumstances – Planned and Emergency. Pre-authorisation of the estimated hospital expense is a must to avail this facility.

Planned Hospitalisation:

In the case of a planned admission, you would have first consulted a doctor who in turn would have advised you on the probable date of hospitalisation. In such a case, you must have applied for an approval of the estimated hospital expenses directly with your TPA at least 4-5 days prior to the date of hospitalisation.

In case you have not applied for a pre-authorisation sufficiently in advance or if the doctor treating you advises you to get hospitalised immediately after the consultation, our Corporate Help Desk will assist you through the pre-authorisation procedure.

However, you will need to bear in mind that the Corporate Help Desk is only a facilitator and can in no way influence the decision on the approval. The approval can be turned down.

The pre-authorisation procedure is detailed below:

Step 1: Establish contact with the Corporate Help Desk at the Hospital

Step 2: At the Corporate Help Desk, you need to present the original health Insurance card issued to you by your TPA

Step 3: Collect the pre-authorisation will forms pertaining to your TPA

Step 4: Your pre-authorisation will have two sections-

1. General details on the health Insurance policy – to be filled in by you (the Corporate desk will assist you in case you have any difficulty)
2. Pertains to the treatment recommended for you-needs to be filled in and duly signed by the Doctor who is treating you (do not attempt to fill this section, contact the Corporate desk in case of any difficulty)

Step 5: Return the completed form to the Corporate Help Desk. The personnel at the desk will verify the form for its completeness and let you know in case of any discrepancy

Step 6: Once the form is complete in all respects, the Corporate Help Desk will fax the form to the office of your TPA.

Step 7: The Corporate Help Desk will revert to you on the approval status

Emergency Hospitalisation:

In case of emergency hospitalisation, the corporate help desk will take up your case on a fast track basis with your TPA and is likely to receive approvals within 3 hours during any working day.

For cashless treatment it is mandatory for the hospital to have an approval from your TPA. Incase of delay in receiving the approval or when you cannot wait for receiving the approval owing to medical urgency you can undertake the treatment by paying the necessary cash deposit.

If you receive approval from your TPA after paying the cash deposit, you are entitled for refund of the cash deposit.

What do I do if I do not get approval on my cost of treatment till the time of discharge at the Hospital?

Cashless hospitalisation is linked to the approval of the estimated expenditure on your proposed treatment. In case you do not get your approval you will need to bear the entire expenditure incurred on the treatment. Therefore it is always prudent to get the approval and then get yourself admitted. You could explain the benefits of getting the approval before the date of your admission to your treating doctor as well when he recommends an immediate admission.

At B. M. Birla Heart Research Centre the Corporate Help Desk will not entertain any request for a refund of the amount paid if the approval comes after the process for your discharge has commenced.

Under what circumstances will the request for cashless hospitalisation not be entertained?

Normally your request for approval might be rejected when:

1. Information contained in the pre-authorisation form is insufficient for the TPA to arrive at a decision and further information is not available for various reasons. However the chances of rejection under this criterion are rare since the Corporate Help Desk at the hospital is experienced in complying with pre-authorisation formalities and will advise you suitably
2. The ailment for which hospitalisation is being sought by you is not covered under your insurance policy for reasons like pre-existing ailment, specific exclusions (accident admission under the influence of alcohol)
3. You have exhausted your eligible Medical Insurance cover for the year.

Does cashless hospitalisation cover all medical expenses?

For complete details on the medical expenses that are covered, and those that are not covered, you need to go through your health insurance policy. However, in general, the expenses listed below are not reimbursable under cashless hospitalisation

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

These need to be settled by you directly to the hospital at the time of discharge

Who are the TPA's with whom B. M. Birla Heart Research Centre has a tie-up?

B. M. Birla Heart Research Centre, Kolkata has a tie-up with several TPA's. (current list is given below). However this is dynamic and will change from time to time. Kindly contact the Corporate Help Desk for an updated list.