Health Insurance Simplified
TIPS FOR MEDICLAIM POLICY-HOLDERS
Taking a mediclaim policy for yourself and the members of your family is the most wise decision for your financial security in case of disease/ailment resulting into hospitalisation. However management of mediclaim policy for better results requires some careful steps.
Apart from it you should keep the list of PPN hospitals (Preferred Provider Network) which is available on the website of four public sector companies. It should be tagged with the policy-docket.
The advantage of getting admitted to PPN hospital is that most of the medical treatments are standardised and it is easier for a TPA to make the cashless settlement. So you are reasonably charged and in addition you get fast claim settlement.
Thirdly, please keep in mind that the Sum Insured under the policy is valid for full one policy-year. If in the very first hospitalisation the hospital overcharges you to squeeze you as much as possible till the S.I. gets exhausted, you are left uninsured for the balance period of policy year. God forbid if you fall sick again warranting hospitalisation, you will have to fund for yourself.
So when the hospital raises bills please examine each item to determine whether these expenses were actually incurred. There are many unscrupulous hospitals which pounce upon the admitted patients if they are having mediclaim cover.
Fourthly you have to keep the xerox set of all medical bills as the originals would be collected by TPA since they are making cashless settlements. It will help you in maintaining your medical records.
Please note that medicines and other treatments taken upto 60 days after the discharge from hospital are also payable. Similarly the treatment taken 30 days prior to hospitalisation related to the disease for which you were admitted is also payable.
In all such cases the original bills and cash memos are to be submitted to TPA for reimbursement.
Lastly, it has to be understood that if all the involved parties, i.e. Insured person, Insurance Company, TPA and Hospitals act honestly and as per code of conduct laid down by IRDA, there would not arise any grievance and the claim shall be processed smoothly.
But in practice the problems do occur which require intervention of a neutral quasi-judicial body. For such exigency please note down the address of Insurance Ombudsman who can be approached for solution. The list of Ombudsmen spread all over India is available on the website of IRDA.
Contributed in the interest of insuring public by
SH. MANOJ KUMAR SINHA
REGIONAL MANAGER (RETIRED, UNITED INDIA INSURANCE CO.LTD.)
TIPS FOR MEDICLAIM POLICY-HOLDERS
Taking a mediclaim policy for yourself and the members of your family is the most wise decision for your financial security in case of disease/ailment resulting into hospitalisation. However management of mediclaim policy for better results requires some careful steps.
First please keep the policy documents in a safe place known to all the members of your family. The name of the insurance company, policy no., period of policy, office address of the insurance company for correspondence and the TPA name & address should be in the knowledge of everybody. It is necessary because in many cases except the main Insured person nobody else is aware. It leads to delay in intimating claim and claims are summarily rejected.
Apart from it you should keep the list of PPN hospitals (Preferred Provider Network) which is available on the website of four public sector companies. It should be tagged with the policy-docket.The advantage of getting admitted to PPN hospital is that most of the medical treatments are standardised and it is easier for a TPA to make the cashless settlement. So you are reasonably charged and in addition you get fast claim settlement.
Thirdly, please keep in mind that the Sum Insured under the policy is valid for full one policy-year. If in the very first hospitalisation the hospital overcharges you to squeeze you as much as possible till the S.I. gets exhausted, you are left uninsured for the balance period of policy year. God forbid if you fall sick again warranting hospitalisation, you will have to fund for yourself.
So when the hospital raises bills please examine each item to determine whether these expenses were actually incurred. There are many unscrupulous hospitals which pounce upon the admitted patients if they are having mediclaim cover.
Fourthly you have to keep the xerox set of all medical bills as the originals would be collected by TPA since they are making cashless settlements. It will help you in maintaining your medical records.
Please note that medicines and other treatments taken upto 60 days after the discharge from hospital are also payable. Similarly the treatment taken 30 days prior to hospitalisation related to the disease for which you were admitted is also payable.
In all such cases the original bills and cash memos are to be submitted to TPA for reimbursement.Lastly, it has to be understood that if all the involved parties, i.e. Insured person, Insurance Company, TPA and Hospitals act honestly and as per code of conduct laid down by IRDA, there would not arise any grievance and the claim shall be processed smoothly.
But in practice the problems do occur which require intervention of a neutral quasi-judicial body. For such exigency please note down the address of Insurance Ombudsman who can be approached for solution. The list of Ombudsmen spread all over India is available on the website of IRDA.
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Contributed in the interest of insuring public by
SH. MANOJ KUMAR SINHA
REGIONAL MANAGER (RETIRED, UNITED INDIA INSURANCE CO.LTD.)
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