" The content is sourced from public domain and is facilitated and provided by Vidal Health care Services Pvt. Ltd. for educational and informational purposes "
Health Insurance earlier entailed the complete settlement of the health care services bill by the individual to the hospital, followed by a reimbursement claim filed with the Insurance Company. The Insurance Regulatory Development Authority in India initiated the Cashless Hospitalization Process through Third Party Administration services for Health Insurance claims from 2002.
- Once you are covered under a Health Insurance Policy administered by us, you will be issued a Vidal Health TPA ID card. If your health insurance cover is issued through your employer, you may not be issued a physical ID card but you may have a E-card. This card will facilitate you to avail CASHLESS facility at the Networked Hospitals.
- Cashless hospitalization can be availed only at our network hospitals. The essence of cashless hospitalization is that the insured individual need not make an upfront payment to the hospital at the time of admission.
- Cashless is only a facility extended by the Third Party Administrators to the Insured persons through their Network of Hospitals who have agreed to certain terms and conditions.
- Cashless cannot be claimed as a matter of right and denial of a pre-authorization request is in no way to be construed as denial of treatment or denial of coverage or denial of your right to prefer reimbursement claim. You can go ahead with the treatment, settle the hospital bills and submit the claim for a possible reimbursement.
- If the policy covering you is subject to the GIPSA PPN arrangement, please check for the nearest hospital that is in the GIPSA PPN Package Agreement. Cashless facility for such policies will be available only in those hospitals who are under the GIPSA PPN Arrangement.
Process for availing Cashless Hospitalisation Facility
- Plan admissions only in such hospitals that are in our Network. If your policy is subject to GIPSA PPN Network, please get admitted only in such hospital that is in the GIPSA PPN Network. Your admission elsewhere will lead to denial of the cashless facility and even reimbursement of the expenses will be subject to the limits as per the GIPSA PPN Tariff.
- Produce the ID Card issued by us at the Hospital Help Desk – along with any other ID Proof like DL/ Voter’s ID/ Passport etc in respect of THE PATIENT.
- Obtain the Pre-authorisation Form from the Hospital Help Desk, complete the Patient Information and resubmit to the Hospital Help Desk.
- Please indicate our ID Card Number without fail. In case the policy is taken by your employer you may also furnish the Employee Number.
- The Treating Doctor will complete the hospitalisation/ treatment information and the hospital will fill up expected cost of treatment.
- This form is submitted to us either online or by fax.
- We will process the request and call for additional documents/ clarifications if the information furnished is inadequate.
- Once all the details are furnished, we will process the request as per the terms and conditions as well as the exclusions therein and either approve or reject the request based on the merits of the case.
Once the request is received, it is processed. Our medical team will determine whether the condition requires admission and the treatment plan is covered by your Health Insurance Policy. They will also check with all the other terms and conditions of your Insurance Policy.
In case coverage is available, we will issue an approval to the hospital for a specified amount depending on the disease, treatment, sum insured available etc. We will send the Approval Letter for Cashless Facility by fax and e-mail (if available) to the Hospital. This approval is called “Pre-authorisation”. This pre-authorisation entitles you to avail the treatment at the hospital without paying for the medical expenses up to the authorised limit.
At the time of discharge, in case the amount authorized by us is not sufficient to cover the hospitalization expenses, the hospital will make a second/ final request on your behalf for sanction of additional amount. We will process this request and sanction of an additional amount will be made subject to terms and conditions of your health insurance policy.
Your policy may be subject to ‘Co-pay’. This is the compulsory amount that you need to bear in respect of each and every hospitalisation claim. Please check for this information. You are required to pay to the hospital the amount equal to the co-pay and obtain the necessary Bill & receipt. The hospital has to submit the proof for having collected this amount from you. If the hospital is not able to produce the requisite proof in respect of collection of co-pay from you, twice the amount of co-pay will be deducted as a penalty from the amount payable to the hospital.
Please verify your policy benefits to check your eligibility for Room Charges etc. An admission to a ward higher than your entitlement would cost your claim as the amount payable will be reduced in proportion the eligible ward charges bear to the higher ward charges billed.
Once final sanction has been received by the hospital, please make sure that you check and sign the original bills and Discharge Summary. Please carry home a copy of the signed bill and the Discharge Summary and all your investigation reports. This is for your reference and will also be useful during your future healthcare needs.
The hospital will ask you to pay for all the Non-admissible Expenses in your bill. You have to make this payment before discharge. You may check for the items disallowed against the Annexure IV of the ‘Standard List of Excluded Expenses in Hospitalization Indemnity policies’ of Exposure Draft – Health Insurance’ by IRDA in the website.
In case, for whatever reason, the pre-authorisation request cannot be approved, a letter denying preauthorization will be sent to the hospital. We may deny the Pre-authorisation without assigning any reason. We may not be able issue Pre-authorisation probably due to insufficient information either from the service provider or the Insurer. In such case, you will have to settle the hospital bill in full by yourself.
Please note that denial of a Pre-authorization request is in no way to be construed as denial of treatment or denial of coverage. You can go ahead with the treatment, settle the hospital bills and submit the claim for a possible reimbursement.