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CASHLESS hospitalisation is not a new concept anymore. If you have one, you would know that a patient could undergo a treatment at any of the hospitals listed with your insurer without having to pay cash at the time of treatment. The payment is usually made by the Third Party Administrators (TPAs). The latter's role primarily being to provide administrative support to the insurance companies for servicing their insurance policies. So as far as you are concerned, TPAs are the main contact point for settling claims. So what do you need to do ? Once the patient is discharged from the hospital you have to forward the concerned medical reports and documents along with the medical bills to the TPA. Then, in return, TPA pays the hospital dues by issuing a letter which guarantees the payment for the treatment you have undergone. But there have been several instances where cashless mediclaim has not really stood up to its definition. In fact, patients have had to pay cash despite having a cashless mediclaim.

The usual woes

The problem customers increasingly face is part payment by TPAs. Medi Assist India chief executive officer Madhavan B says "This trend will continue until the hospitals standardise the rates. There is also a lack of standardisation in billing documents, which adds to administrative problems."

There could be two ways in which you might be asked to pay money, despite you buying a cashless mediclaim policy. One way is that the TPA approves a part of the amount and the balance has to be borne by you for the time being till the final bill is produced by the hospital. Once the final bill is produced at the time of discharge, the concerned TPA will pay up the balance amount to the hospital. The hospital in turn would repay the patient. Under the second method, the TPA sanctions only a part of the total estimated amount and you have to pay off the balance. Then the TPAs will reimburse the balance in 20 days.

TPAs sanction the claim amount based on a clause called "customary and reasonable charges". Insurers promise that they will reimburse the entire medical cost incurred by the policyholders but medical costs are becoming more subjective these days, the TPAs say. There is a difference in interpretation between the necessary charges and reasonable charges. "While the Tier II and Tier III hospitals are agreeable to the rates negotiated by TPAs, the premium and Tier I hospitals work on their own terms and conditions when it comes to costing, says another TPA under conditions of anonymity. In most cases, the reasons for a part sanction of the total amount by the TPA are, lack of clarity on break-up of charges given by the doctor and secondly, fear of misuse of funds by the hospital. How to ensure a smooth claiming process? First of all, ensure that the policy holder who has to undertake the medical treatment should talk to the TPA before hospitalisation. The policy holder has to get an estimate of the medical cost that would be incurred for treating the ailment from the hospital. Once the TPA receives your request it finds out whether the amount mentioned complies with their "customary and reasonable charges" clause. Then the TPA will be giving you an idea of how much will it reimburse as the claim amount.

"Now what happens is most clients rush to the hospital at the eleventh hour, even in case of planned surgeries/treatment. This adds to claim worries", Mr Madhavan adds. Most cashless mediclaim do not cover OPD consultation /procedure /investigation done in pre-hospitalisation period.