Insurance and TPA

LIST OF TPA’S (THIRD PARTY ADMINISTRATION) ON PANEL

  • Alankit Health Care Ltd.
  • Apollo Munich Health Insurance Company
  • Bajaj Allianz Health Care
  • Dedicated Health Care
  • E-Meditek TPA Services Pvt Ltd
  • East West Group Ltd.
  • Ericson TPA Pvt Ltd
  • Family Health Plan Ltd.
  • Focus Health Health Care
  • Future Generali India Insurance Company
  • Genins India Ltd
  • Good Health Plan Ltd.
  • HDFC Ergo TPA Insurance
  • Happy Insurance TPA Pvt Ltd
  • Health India TPA Services Pvt Limited
  • Hygiecare
  • Heritage Health
  • ICICI Prudential
  • I-Care Health

Registered with Delhi Govt (DHS/NH/066) / Income Tax Exempted

  • L&T TPA Pvt Ltd.
  • MD India Ltd.
  • Medi Assist Ltd.
  • Medicare
  • Medsafe TPA
  • Park Mediclaim
  • Paramount Health Care
  • Raksha TPA Pvt Ltd
  • Reliance Health Check-up.
  • Religare Health Insurance Company Ltd
  • Rothsheild Health Care Pvt. Ltd.
  • Royal Sundaram Insurance
  • Safeway Healthcare
  • Star Health India Ltd.
  • Spurthi TPA
  • TTK Health Services
  • United Health Care / Parekh
  • Vipul MedCorp Ltd

LIST OF PUBLIC SECTOR UNDERTAKING ON PANEL

  • Airport Authority of India (International Airport & National   Airport)
  • Maruti Udyog Limited
  • Indian Drug & Pharmaceuticals Limited
  • Reserve Bank of India
  • Bharat Electronics Ltd.
  • HUDCO
  • MTNL Retired Employees
  • Delhi University
  • Delhi Development Authority
  • JNU
  • The State Hydroelectric Power Corp.
  • National Projects Construction Corp.
  • Delhi Metro Rail Corporation
  • Indian Airlines

GUIDELINES FOR PATIENTS AVAILING CASHLESS TREATMENT UNDER HEALTH INSURANCE POLICY (Cashless Mediclaim Policy)

The essence of Cashless Hospitalization is that the insured individual need not make any upfront payment to the designated/empanelled hospital for treatment. To avail Cashless benefit without any inconveniences you need to go through the following:

 

1. Empanelment of Hospital

Before Admission Please confirm with our Admission Desk/Medical Insurance Desk whether your Insurance Company/TPA is registered with us. The following Insurance Companies / TPAs are associated with us:

  • MEDICARE
  • FHPL
  • PARAMOUNT
  • HERITAGE
  • E-MEDITEK
  • Safeway
  • Park
  • UNITED HEALTH CARE
  • ihealthcare
  • Medsave
  • FHPL
  • Happy health insurance
  • Religare
  • APOLLO MUNICH
  • FUTURE GENERALLI
  • I-CARE
  • STAR HEALTH
  • GOOD HEALTH PLAN
  • MD India
  • MEDI ASSIST
  • ICICI Prudential
  • Focus
  • BAJAJ ALLIANZ
  • Health India
  • Medsafe
  • L&T
  • Vipul
  • MaxBupa
  • RAKSHA
  • GENESIS

2. Pre Requisite for Admission

At the time of Admission it is mandatory to produce the following documents issued by your Insurance Company/TPA at our Admission Desk:

  • Valid TPA/ Insurance Card
  • Proof of Identity
  • Policy Documents

Immediately after admission of the patient, his/her next kin should contact our Medical Insurance/Reception/TPA Desk for signing pre – authorization form and submission of the following documents: Doctor’s advice for admission, ID card issued by TPA/Current Policy Papers etc as may be required.

 

3. How your Claim is processed

Processing of a Health Insurance claim is time taking and you are requested to please bear with us. The following is an over view of the claims process:

Step 1: Patient presents for admission

Step 2: Filling up of the Pre Authorization Form by treating doctor and sending to TPA/Insurance Company Concerned and waiting for initial approval. The estimated amount of expenditure is mentioned here.

Step 3: TPA/ Insurance Company may revert back with queries if any which are replied by the hospital.

Step 4: TPA/ Insurance Company sends provisional approval as per patient’s policy details.

Step 5: Patient is allowed to undergo treatment at the hospital as per approval

Step 6: Prior to discharge the final bill, treatment details & the discharge summary of the patient is sent to the TPA/Insurance Company for final approval.

Step 7: TPA/Insurance Company may have multiple queries which have to be replied to by the hospital. Approval is not sent till all queries have be answered and the TPA/Insurance company is totally convinced that treatment has been done as per approval.

Step 8: After final approval is received the patient is clear for discharge..

 

4. TPA / Insurance Processing Fee

A processing Fee of Rs150/- will be charged to the patient for processing the entire insurance claim.

This Fee is neither Reimbursible nor will it be adjusted in any for( Be it Final Bill or in between during the course of Hospitalization)

 

5. Follow up during the period of Hospitalization

During the period of treatment, the patient’s kin should keep liaison with our TPA DESK on a regular basis to know the development. Your insurance Company/TPA may send queries for which our executives may need your help to reply to.

 

6. Important : When can you be asked to pay even if you have Cashless Insurance Policy

It is our endeavor to provide cash less benefit to our Insurance patients but due to many a reason the same may not be possible at times. You may be requested to make payments in the following situations:

  • Denial of your Claim by the Insurance Company/TPA. Hospital will not be responsible for such denial and in that case the patient will have to clear the hospital dues before discharge of the patient.
  • The TPA/ Insurance Company may pay a part of the total bill. In that case the patient will have to settle the balance amount prior to discharge. Your policy may mention for a Co-Payment clause wherein the beneficiary will have to pay a part of the bill.
  • Most health Insurance Companies/TPAs have adopted a system of capping on bed charges to 1% of the policy amount. If the beneficiary avails any facility beyond his/her entitlement then he/she will have to pay the difference amount to the hospital prior to discharge.
  • Your Health Insurance Company/TPA does not pay for everything. Certain expenses like service charge, cost of diaper, hand gloves, extra food, telephone bill, nutritional supplements etc are to be paid by the patients. These are called as NON ADMISSIBLE EXPENSES. Please refer to the annexure to know the common list of such non admissible expenses that you may have to pay for. For a detailed list of exclusions please refer to your policy document.

 

7. Discharge Process

As per the system adopted by most Health Insurance Companies/TPAs, the final sanction is sent only after getting the discharge summary and the Final Bill. Hence even after the discharge advice of the doctor, patient may have to stay in the hospital for further few hours till such sanction is received by the hospital.

 

8. Planned Admission

For any planned treatment (surgery) it is advisable to get approval for cashless benefit from your Health Insurance Company/TPA before the patient is admitted in the hospital. To get such approval please contact our MEDICAL INSURANCE/TPA DESK with following documents: Doctor’s advice for admission, I.D Card issued by your Health

Insurance Company/TPA, Current Policy Documents, All reports of investigations done to determine the treatment.

 

9. Emergency Admission

In case the patient is admitted under emergency conditions then the required documents must be submitted within 24hours of admission. Hospital will not be responsible for denial of claim by your Insurance company/TPA due to delayed submission of documents.

 

10. Insurance / TPA Help Desk

In case of any assistance or queries regarding your claims processing please feel free to contact our Insurance / TPA Desk on the Ground Floor. (9:30 AM to 6PM)

LIST OF COMMON NON-ADMISSIBLE ITEMS/EXPENSES

(Patient will have to pay for these expenses at the time of discharge)

Administrative expenses

  • Admission charges
  • Registration charges
  • Medico-legal charges
  • Attandant stay charges
  • Relative stay charges
  • Additional stay
  • Gate pass/Attendant pass
  • Conveyance charges
  • Booking charges
  • Overhead charges
  • Establishment charges
  • Tax/Luxury charges
  • Incidental charges
  • Waste disposal charges

 

Documentation Expenses

  • Documentation charges
  • Discharge summary
  • Medical records Charges
  • Birth certificate
  • Death certificate
  • TPA charges

 

Appliances

  • Water bed/Air cushion
  • Alpha bed
  • Hot water bag
  • Bed pan/Kidney tray/Sputum cup
  • Cruches/Walker/Wheel chair
  • Braces/Cervical collar
  • Slings//Splints
  • Knee caps
  • Abdominal Belt/LS belt
  • Nebulizer/Steam inhaler/Humidifier
  • Thermometer
  • Chest binder
  • Spirometer
  • Spacer
  • Infusion pump
  • CAPD equipment
  • Glasses/lenses/goggles/frames
  • Dentures/dental bcases/implants
  • Hearing aids

Services

  • Private nurse charges
  • Telephone charges
  • Fax charges
  • Food/beverages
  • Diet & dieticean charges
  • Electricity charges
  • Water charges
  • T.V/Internet charges
  • News paper/Magazine
  • A/C charges
  • Stationary charges
  • Lines/Laundry charges
  • Mortuary/coffin charges
  • Ambulance charges
  • Housekeeping charges
  • Preparation charges
  • DONOR charges
  • Vaccination charges
  • Outstation consultants/surgeons
  • Referral charges
  • HIV charges
  • RMO/duty doctor charges
  • Assistant charges for minor cases
  • Expenses towards sterlization

 

Consumables

  • Antiseptic/disinfectant solutions
  • Soap
  • Powder(talc)
  • Oil
  • Cream
  • Sanitary pads/Diapers
  • Toiletries & stationary & cosmetic expenses
  • Cassette/CD/Film charges
  • Oxygen cylinder
  • ECG electrode charges

 

Network deduction only when mentioned on the loc

  • Co pay
  • Baby expenses
  • Excess room rent
  • Limit . Eg . Maternity
  • Pre existing condition
  • Expenses not pertaining to diagnosis
  • mentioned in the pre auth

Please comply with the above mentioned conditions to help us serve you better.

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