Transcript Reliance HealthWise Policy PPT

Reliance
HealthWise Policy
December 2006
December 2006
Agenda
1. Introduction - Clinical Indian Health Industry and Health Insurance
2. Product Offering – Reliance HealthWise Policy
3. Underwriting Overview
4. Claims Overview
December 2006
Introduction

Health Risks could arise from various factors such as
 Physical Condition
 Psychological Conditions
 Occupation
 Lifestyle Related Factors

Growing concern over prevalence of chronic illnesses in India
 obesity
 heart-illnesses
 diabetes and hypertension among others
These factors will have significant impact on the health-care cost.
December 2006
Our Life Style.. A Ticking Time Bomb
Tremendous change in our life style
 More nuclear families…more responsibilities
 Late working
 Extreme work pressures
 No time for self
 Not eating on time…eating out
 Eating unhealthy….junk food
 High inflation….everything getting expensive
December 2006
Our Life Style.. A Ticking Time Bomb
Alarming Symptoms
December 2006

Increased risk of falling sick

More and more younger people fall sick

One has to pay heavily for medical treatments

Medical costs directly affect one’s hard earned
savings

Savings which were meant for important needs
is drained on medical expenses
Our Daily Solemn Promise – what we should do

Every day I promise to myself
• I will get up early and go for a walk
• I will come home early after office
• I will eat on time
• I stop drinking..Ok ..Only a little bit
• I will eat healthy, absolute NO to junk food
• Go to a gym..Take care of my health
• I will sleep early
As Promises are meant to be broken..so I break them every day!!
December 2006
The Next Best Alternative….
It’s never too
early to
plan for future…..
Health Insurance…
December 2006
Need for Health Insurance

Urban Lifestyle and Rural Infrastructure support

Inadequate Facilities in Government Hospitals

Privately run hospitals are expensive

Increased cost of medication
 Diagnostic Expenses have spiraled
 Specialist Doctors come expensive

Increasing Population with income disparity

More nucleus family means less savings and less disposable income

Changing disease profile and lack of Medical Information
December 2006
Current Market Scenario

Only 85m people in India are covered under Health Insurance

Among them, only 10.8m are covered by Insurance Companies

The rest are covered under government and company schemes

Contributes to 9.6% of the general insurance market

Intense competition among the public and private players

Historically perceived as a loss making portfolio
•
Lack of spread of risk
•
Lack of adequate Underwriting guidelines
•
Inadequate claims control
•
High perceived fears of fraud and abuse

Very little variation in product and price among the insurance providers


Inadequate distribution
Coverage of Pre-existing diseased - still a question
December 2006
Healthcare Opportunity in India - Mckinsey report

Healthcare spending in the next 10 years will Double

Healthcare spending will increase to 2,00,000 crores by 2012 (Rs.86,000
crores in 2000-01)

Health care insurance sector is to become a
 Rs 25,000 crore industry by 2009 (Rs.1200 crores- in 2001-02)
 Rs 75,000 crore by 2020
December 2006
The Way Forward….

Increased customer awareness for more spread of insurance

Higher standards of customer service

Popularisation of Floater Concept

Reduction of Claim Ratio through efficient underwriting guidelines/ control /
product offerings / spread of risk

Value Adds and Increased Features which further sweetens the product

Affordable pricing – cross subsidize across age categories

Increased Marketing Communication

Increased Cashless Coverage through TPA

Ensure Hassle-Free Policy Issuance and Claim Procedures

Inclusion of Preventive elements
December 2006
Agenda
1. Introduction - Clinical Indian Health Industry and Health Insurance
2. Product Offering – Reliance HealthWise Policy
3. Underwriting Overview
4. Claims Overview
December 2006
What is Reliance HealthWise Policy?
Reliance HealthWise Policy provides for …………….
Financial Assistance for you and your family against Hospitalisation
Expenses towards disease / illness / injury in India along with host of
value additions / options
December 2006
Reliance HealthWise Policy
1. Basic Features
2. Value Added Features
3. Policy Features
4. Exclusions
5. Plan Details
6. Our Advantage
December 2006
1. Basic Features
a. Hospitalisation Expenses
b. Daycare Treatment
c. Domiciliary Hospitalisation
d. Pre and Post Hospitalisation
e. Coverage of Pre-Existing Diseases
f. Critical Illness Cover
g. Donor Expenses
December 2006
1.a. Hospitalisation
Covers hospitalisation expenses incurred as an in-patient in a Hospital which
will include
• Room, Boarding and Operation Theatre charges
• Fees of Surgeon, Anesthetist, Nurses, Specialists
• The cost of diagnostic tests, medicines, blood, oxygen, appliances
like pacemaker, artificial limbs and organs etc
Hospitalisation for a minimum period of 24 hours is a must
The cover provided is to a maximum of the Sum Insured
as selected by the Customer
December 2006
1.b. Day Care Treatment
Hospitalisation less than 24 hrs
Due to advancement of technology, hospitalisation expenses for certain
treatments / diseases like the following are also covered, even though the
hospitalisation is for less than 24 hours
•
•
•
•
•
•
Cardiac Catheterization
Cataract
Chemotherapy
Coronary Angiography
Coronary Angioplasty
Dialysis
December 2006
•
•
•
•
•
•
•
Dilation & Curettage
Eye Surgery
Hernia Repair Surgery
Hydrocele Surgery
Lithotripsy (Kidney stone removal)
Radiotherapy
Tonsillectomy
1.c. Domiciliary Hospitalisation
Medical Treatment at your Home
Medical Treatment for a period exceeding three days, which in the normal
course, would require hospitalisation, but treatment is actually taken at home,
under any of the following circumstances: 
the condition of the patient does not permit him/her to be removed to
Hospital or

the patient cannot be admitted to Hospital for lack of accommodation
therein
This benefit also covers expenses on employment of a qualified nurse, as
recommended by the attending Doctor.
December 2006
The cover provided is to a maximum of 10% of the Sum Insured
as selected by the customer
1.d. Pre and Post Hospitalisation
Extended Pre and Post Hospitalisation
Policy also covers relevant medical expenses incurred during a specified
period, before & after hospitalisation (for which a claim is payable)
December 2006
1.e. Coverage of Pre-Existing Diseases
Pre-Existing Diseases Coverage
Hospitalisation expenses incurred on treatment towards Pre-existing diseases /
condition can be covered:
 Gold Plan: after completion of 2 consecutive years of the policy period
 Silver Plan: after completion of 2 consecutive years of the policy period
 Standard Plan: after completion of 4 consecutive years of the policy period
December 2006
1.f. Critical Illness Cover
Double Sum Insured Benefit
If Insured contracts any of the following nine Critical Illnesses, the Sum
Insured under the Policy (chosen by the Insured), is doubled towards
hospitalisation expenses incurred for treatment of such Critical illness.

Cancer

Coronary Artery Bypass Surgery

First Heart Attack

Kidney Failure

Multiple Sclerosis

Major Organ Transplant

Stroke

Aorta Graft Surgery

Paralysis

Primary Pulmonary Arterial Hypertension
This feature is available only in Gold Plan
December 2006
1.g. Donor Expenses
Major Organ Transplant
Covers hospitalisation expenses towards donor in case of major organ
transplant.
This feature is available to customers of Gold and Silver Plans
December 2006
2. Value Added Features
Value added benefits are payable up to the Sum Insured for the plan opted.
a.
b.
c.
d.
e.
f.
Expenses on accompanying person at the Hospital
Local Road Ambulance Services
Recovery Benefit
Cost of Health Check up
Nursing Allowance
Hospital Daily Allowance
These features become applicable once a valid claim is admitted under
the basic hospitalisation expenses cover of the Policy
December 2006
2.a. Expenses on Accompanying Person
Payment towards expenses incurred by an accompanying person at the
hospital while Insured is hospitalised for a minimum period of 5 days.

Gold Plan: Rs. 300/- per day for a maximum of 5 days

Silver Plan : Rs. 250/- per day for a maximum of 5 days

Standard Plan : Rs. 200/- per day for a maximum of 5 days
This is a common feature available to all Policyholders
December 2006
2.b. Local Road Ambulance Services
Reimbursement of Expenses incurred for necessary transportation of the
insured to the Hospital in an ambulance for hospital admission and requiring
immediate treatment.
Maximum limit:

Gold Plan – Rs. 1000/-

Silver Plan – Rs. 750/-

Standard Plan – Rs. 500/-
This is a common feature available to all Policyholders
December 2006
2.c. Recovery Benefit
In an unfortunate event, if the Insured is hospitalised for more than 10
consecutive days, a lump sum benefit of Rs. 10,000 will be payable as Recovery
Benefit.
Basic Hospitalisation claim is enough. No need to provide for bills as this is a
benefit payment.
This benefit is applicable for

All the members of the floater separately

Irrespective of the number of occurrence during the policy period
This feature is available only to customers of Gold Plan
December 2006
2.d. Cost of Health Check up
This benefit provides for reimbursement of cost / charges incurred for medical
check up.
 Applicable once at the end of a block of 4 claim free years.
 Reimbursement is limited to 1.25% of the average sum insured.
This is a common feature available to all Policyholders
December 2006
2.e. Nursing Allowance
Payment of Nursing Allowance for expenses towards employment of registered
nurse at the residence of Insured or at the Hospital provided such services are:

Confirmed as being necessary by the treating Physician

Relate directly to a disease / illness / injury for which the Insured has been
hospitalised.
This is applicable irrespective of the number of times of occurrence
Allowance is payable for 5 days. In case of Critical Illness under Gold Plan this
is payable for 10 days.

Gold Plan
Rs 300/- per day

Silver Plan
Rs. 250/- per day
This feature is available to customers of Gold and Silver Plans
December 2006
2.f. Hospital Daily Allowance
Daily Hospital Allowance of Rs. 250 per day up to 7 days will be paid to
Insured, provided he/she is hospitalised for more than 3 days.
 It is irrespective of the number of occurrences
 If case two people of the same floater are hospitalised, concurrently, each
one of them will be eligible for hospital daily allowance separately
This feature is available only for Gold Plan customers
December 2006
3. Policy Features
a. Income Tax Benefit
b. Family Floater
c. Sum Insured
d. Pre-insurance Health Check up
e. Option in Policy Duration
f. Renewal Discount
g. Cashless Facility (Through Third Party Administrators - TPA)
h. Age Slabs
December 2006
3.a. Income Tax Benefit
Premium paid for Reliance HealthWise Policy is eligible for tax deduction under
section 80 D of the Income Tax Act, subject to the condition that the
premium amount is paid by cheque/DD by the customer from his bank
account.
 Rs. 10,000/- for self, spouse, kids and parents
 Rs. 15,000/- if the policy includes senior citizens whose ages is above 65
yrs
December 2006
3.b. Family Floater
Policy can be issued on a Floater basis covering the family members of the
Insured comprising the Insured, spouse and two dependant children (upto the
age limit of 21 years).
What is floater, how does it benefit?

All members of the family (Self, Spouse, 2 Kids)
can be covered under one single policy

Single premium payable for the entire family

The amount of Sum Insured “floats”
over the entire family

No need to insure individual members separately

No hassles of tracking renewals for different members
December 2006
3.b. Family Floater - Illustration
Family: Mr. Ashish Sethi, Mrs. Sethi & their kid Nikki
Scenario 1:

They take an insurance policy with a SI of Rs.1 Lakh each

Mr. Sethi unfortunately needs to undergo angioplasty

The total bill amount Rs. 1.4 lakhs

Insurance company pays only Rs. 1 Lakh as he is covered for only 1 Lakh.
He cannot adjust the rest in the unused coverage amount of his wife and
daughter

Mr. Sethi needs to bear the reminder of the cost – i.e. Rs, 40,000!!
December 2006
3.b. Family Floater - Illustration
Family: Mr. Ashish Sethi, Mrs. Sethi & their kid Nikki
Scenario 2:

They take a Reliance Healthwise Policy with a SI of Rs. 3 Lakh for the family

Mr. Sethi unfortunately needs to undergo angioplasty

The total bill amount Rs. 1.4 lakhs

The entire amount is paid for by Reliance HealthWise Policy

Mr. Sethi does not need shell out any money out of his own picket
December 2006
3.b. Your Choice!
OR
December 2006
3.b. Advantage Floater!
Chance of all in the Sethi family falling ill in one year is low as compared to
one member falling severely ill – Theory of probability
Individual
Floater
Single cover for each member
Common cover for all members
No flexibility to transfer the unutilized limit
for other members
The limit can be used by any member of
the family & for any number of times
Separate policy (separate document) for
family members
Single document, single premium, single
date to track
Premium payment annual in nature
For the 2 year option, premium payment
once in 2 years (at the beginning)
Currently, all plans annual in nature
Floater plan available for one/two
years..so assured zero hassle renewal
next year
December 2006
3.b. Fits all in the Family

Family covered under floater policy

Choice to cover
 Individual
 Couple
 Couple & One kid
 Couple & Two kids

Choice of cover amount
 Rs. 1 to 5 Lakh per family depending on the plan selected
December 2006
3.c. Sum Insured
Wide range of Sum Insured option depending upon his medical requirement:

Gold Plan: 1 lac, 2 lac, 3 lac, 4 lac, 5 lac

Silver Plan: 1 lac, 2 lac, 3 lac, 4 lac, 5 lac

Standard Plan: 1 lac, 2 lac, 3 lac, 4 lac, 5 lac
December 2006
3.d. Two Year Policy Option

The Reliance HealthWise Policy offers to the Insured an option of

1 year Policy

2 years Policy
If two year policy option is taken……………….


No worries for the insured members regarding:

Any price increase

Remembering to renewing the policy again next year
Premium to be paid for 2 years at the beginning itself
December 2006
3.e. Pre-insurance health Check up

No medical tests required at enrollment stage for family members under the
age of 45 and the Policy is issued immediately based on proposal form and
declaration

Applicants above 45 yrs will be covered only after completion of medical
tests, submission of reports and the approval of Underwriting team
December 2006
3.f. Renewal Discounts

A renewal discount of 5 % on the renewal premium will be allowed, in case
no claim is made during the expiring policy period

This renewal discount can be accumulated upto a maximum of 50%
December 2006
3.g. Cashless Facility (Through TPA)

Each Policy holder will get a Health Card

Using Health Card the Insured can avail of Cashless Hospitalisation facility
through contacting the TPA

Cashless facility is available in over 3000 networked hospitals across the
country

TPA provides assistance in
 Cashless hospitalisation
 Information on Claims status
 Information on Hospitals
 24 hour helpline
(TPA - Third Party Administrators)
December 2006
3.h. Age Slabs – Applicability

Anyone between the age of 3 months to 65 yrs can be covered under the
various plans

No fresh policy to be issued after 55 yrs in case of Gold Plan; 60 yrs incase
of Silver Plan; 65 yrs incase of Standard Plan

3 months - 45 yrs can be covered without Pre-insurance medical tests

46 yrs & above Mandatory medical test & necessary approval from the UW
Age band
Coverage
3 months to 5 yrs
Covered only along with either of the parents without any medical
examination
6 years to 45 yrs
Covered without any medical examination.
46-65 yrs
Covered subject to satisfactory medical examination
December 2006
4. Exclusions
First year Exclusions
There are certain ailments which are not covered for the First year of inception of
health insurance cover, but are covered subsequently –
 Cataract
 Benign Prostatic Hypertrophy
 Myomectomy, Hysterectomy or menorrhagia or fibromyoma unless because
of malignancy
 Dilation and curettage
 Hernia, hydrocele, congenital internal disease, fistula in anus, sinusitis
 Skin and all internal tumors/ cysts/nodules/ polyps of any kind including
breast lumps unless malignant /adenoids and hemorrhoids
 Dialysis required for chronic renal failure
 Gastric and Duodenal ulcers
December 2006
This exclusion will not apply for roll over cases
4. Exclusions
Permanent Exclusion

Disease/ Injury existing before inception of health insurance policy being preexisting disease (however, these will be covered after 2nd year, depending
on the choice of plan)

Any disease contacted during the first 30 days of inception of policy –
accidents excluded and roll over cases excluded

Naturopathy or other forms of local medication

Pregnancy & childbirth related diseases

Intentional self-injury / injury under influence of alcohol, drugs

Diseases such as HIV or AIDS

Diseases existing from the time of birth (Congenital diseases)
December 2006
4. Exclusions contd……..

Cost of spectacles, contact lenses and hearing aids

Dental treatment or surgery of any kind unless requiring hospitalization

Charges incurred at Hospital or Nursing Home primarily for diagnostic
without any treatment

Expenses on vitamins and tonics unless forming part of treatment for disease
or injury as certified by the medical practitioner

Cosmetic, aesthetic, treatment unless arising out of accident

Treatment related to obesity

War, riot, strike, terrorism, nuclear weapons induced hospitalisation

Routine medical, eye and ear examinations

Treatment of mental illness
December 2006
5. Plan Details
Plan Comparison – Basic Features
December 2006
5. Plan Details
Plan Comparison – Value added Benefits
December 2006
5. Plan Details
Plan Comparison – Policy Features
December 2006
6. Our 17 points Advantage!
1. Family Floater Option
2. Coverage of Pre-Existing Diseases after 2nd year of renewal
3. Automatic Double Sum Insured under Critical Illness cover
4. Policy duration for 2 years
5. Extended Pre and Post-hospitalisation
6. Wider Sum Insured options
7. Hospital Daily Allowance
8. Nursing Allowance
9. Recovery Benefit
10. Reimbursement of Cost of Health Check up after 4 years
11. Local Road Ambulance Services
12. Expenses on Accompanying Person
13. Cashless Facility
14. Policy without Medical test till 45 yrs
15. Renewal Reward - No Claim Bonus
16. Income Tax Benefits
December 2006
And you tell me the Last
Advantage…. The 17 advantage
6. Our 17 points Advantage!
17. Instant Policy Issuance
December 2006
6. Reliance Healthwise Vs. Other Cos.
December 2006
6. Reliance Healthwise Vs. Other Cos.
December 2006
6. Reliance Healthwise Vs. Other Cos.
December 2006
Agenda
1. Introduction - Clinical Indian Health Industry and Health Insurance
2. Product Offering – Reliance HealthWise Policy
3. Underwriting Overview
4. Claims Overview
December 2006
Product Code

Reliance HealthWise Policy
 Product Code - 28-25
December 2006
Proposal acceptance authority – fresh proposal
Acceptance Authority
Type of
Proposal
Age Band
Fresh Proposals
3 Mths - 45
46 -55
56-65
(Applicable to
Standard &
Silver Plans
Only
December 2006
Branch Office
Regional Office
Front Line Office can accept
business based on clear
proposal form where there is
no pre-existing disease.
Where proposal form states
pre-existing disease,
proposal form as to be
referred to Regional Office
Proposal referred to by the
Front line office with preexisting disease may be
considered for acceptance
based on underwriting.
RO can accept the
proposal subject to medical
examination. Only such
medically cleared proposals
are to be underwritten by
the RO for this age group .
Any deviation refer to CO
Corporate
Office
NA
CO may
consider
acceptance
depending on
merits of each
case
Medical
Test
No Medical
Required
Medical
Required
Medical
Required
Proposal acceptance authority – renewal / rollover proposals
Acceptance Authority
Type of
Proposal
Renewals or Rollovers
Branch Office
Regional Office
3 Mths - 45
Proposal/Renewal
with “No Claim”
maybe accepted
Proposal/Renewal with claim
history may be consider
based on underwriting
No Medical
Required
Proposal/Renewal maybe
accepted where there is
"No Claim"
No Medical
Required
46yrs -55
yrs
56 yrs –
65yrs
(Applicable
to Standard
& Silver
Plans Only
December 2006
Proposal/Renewal maybe
accepted where there
is "No Claim"
Corporate Office
Medical
Test
Age Band
Proposal/Renewal
with claim history
may be consider
based on
underwriting
No Medical
Required
Endorsements - Non premium bearing endorsements
 Change in the following;
• Correction in Name of the Insured and/or dependants (only spelling)
• Correction in Gender
• Correction/Change in Address
• Correction on Date of Birth provided no impact on the premium
• Correction in Relationship of the dependants
• Change in Nominee
 Cancellation of Policy due to dishonor of Cheque
December 2006
Endorsements - Premium bearing endorsements
Endorsements resulting in Refund
1) Cancellation
 at the request of the Insured (short period rate) subject to no claim policy.
 at the instance of the Insurance Company (pro rata basis)
2) Deletion of Insured Members
 only in case of legal separation and/or demise of Spouse or demise of child
 premium to be refunded subject to no claim paid
3) Change in Date of Birth of the oldest member of the family
 resulting in charging a lower premium due to reduction in age shall be done on
receipt of written request from the Insured and proof of Date of Birth. (Proof of DOB
can be Birth certificate, copy of Passport, Pan Card, driving license and the like)
 premium will be refunded pro rata basis
December 2006
All the above are subject to UW approval
Endorsements - Premium bearing endorsements
4) Reduction in Period of Insurance

No reduction on Period of Insurance is allowed
5) Degradation of Plan

No mid term degradation of plan to be allowed
6) Decrease in Sum Insured

No mid term decrease in Sum Insured to be allowed
All the above are subject to UW approval
December 2006
Endorsements - Premium bearing endorsements
Endorsements resulting in collection of additional premium
1) Inclusion of dependants
 Mid term addition is allowed only in the following cases
• New Born Child ( to be intimated within 4 months of birth)
• Newly married Spouse, ( to be intimated within 2 months of marriage)
 Premium in case of the above scenario to be collected on pro rata basis
 Under no other circumstances addition of family members is allowed
2) Change in Date of Birth of the oldest member of the family
 Resulting in charging a higher premium due to increase in age shall be done on
receipt of written request from the Insured and proof of Date of Birth. (Proof of
DOB can be Birth certificate, copy of Passport, Pan Card, driving license and the
like)
 Premium will be colleted on pro rata basis
December 2006
Endorsements - Premium bearing endorsements
3) Increase in Period of Insurance
 No mid term increase in Period of Insurance is allowed
4) Upgradation of Plan
 No mid term upgradation of plan to be allowed
5) Increase in Sum Insured
 No mid term increase in Sum Insured to be allowed
All the above are subject to UW approval
December 2006
Agenda
1. Introduction - Clinical Indian Health Industry and Health Insurance
2. Product Offering – Reliance HealthWise Policy
3. Underwriting Overview
4. Claims Overview
December 2006
Types of claims - Hospitalisation
Claims can be broadly of two types:
 Reimbursement claims
 Cashless claims
This further can be broken into:
 Planned - Where the customer is aware of the hospitalisation atleast 72 hours in
advance
 Emergency - Where the customer meets with an accident or suffers from bout of illness
that requires immediate admission to the hospital
Claims are serviced at both network as well as non-network hospitals
 Network hospitals – Hospitals which are on the tied up list (more than 3000 hospitals
covered) - Where our service provider has a relationship
 Non-network hospitals – which do not form part of the list
December 2006
Reimbursement - Steps to follow during hospitalisation
A) Emergency hospitalisation



Step 1.
Step 2.
Step 3.

Step 4.
Take admission into the hospital.
As soon as possible, inform TPA about the hospitalisation.
At the time of discharge, to settle the hospital bills in full and
collect all the original bills, documents and reports.
Lodge the claim with TPA for processing and
reimbursement by duly filling in the claim form & enclosing all
original bills/vouchers/receipts
B) Planned hospitalisation



Step 1.
Step 2.
Step 3.

Step 4.
December 2006
Inform TPA about the planned hospitalisation.
Get admitted into the hospital as planned.
At the time of discharge, to settle the hospital bills in full and
collect all the bills, documents and reports.
Lodge the claim with TPA for processing and
reimbursement by duly filling in the claim form & enclosing all
original bills/vouchers/receipts
Reimbursement Claims - Claim procedure

As soon as hospitalised, to intimate the TPA (Help line/Toll free number
mentioned in the Health Card)

Following information needs to be furnished while intimating a claim:
• Contact Numbers
• Policy Number (as reflecting on the Health Card)
• Name of Insured person who is Sick or Injured
• Nature of Sickness/Accident
• Date & Time in case of accident, commencement date of symptom of
disease in case of sickness
• Location of accident
December 2006
Cashless Claims – Procedure (Approval)
 Cashless Service is the service wherein the Insured need not pay any money
at the time of admission or discharge.
• This facility is available only at our Network Hospitals
 To avail the “Cashless Service”
• “Cashless Request Form” available in network hospital (and in the H Kit)
is to be filled up and sent to TPA for getting authorisation from TPA. The
Hospital will coordinate for this.
• This authorisation along with a copy of the Health Card has to be given to
the Network Provider at the time of admission
• Please also keep a copy of any photo ID card, it may be required by the
Hospital.
TPA will authorize “Cashless Service” at the Network Hospitals for all
cases which are covered under the policy.
December 2006
Cashless Claims - Procedures (Denial)
“Cashless Service” may be denied in following situations:

In case of any doubt in the coverage of treatment of present ailment under
the Policy

If the information sent to TPA is insufficient to confirm coverage

The ailment/condition etc. not being covered under the policy

If the request for pre-authorisation is not received by TPA in time
Denial of “Cashless Service” is not denial of treatment. The Insured can
continue with the treatment, pay for the treatment to the hospital and after
discharge send the claim to TPA for processing.
December 2006
Cashless Claims - Procedures for emergency hospitalisation
 Rush to hospital and get admitted.
 Obtain the Pre-Authorisation Form from the hospital (if it network).
 Get the same filled in & signed by the attending doctor with required details.
 Fax the pre-authorization form along with necessary medical details to TPA at
the number mentioned in health card. The Hospital will coordinate for this.
December 2006
Cashless Claims - Procedures for emergency hospitalisation
If pre-authorisation is received from the TPA for “Cashless Service”
 At the time of discharge………….
• Verify the bills and sign on all the bills at the Hospital.
• Pay only for those items that are not reimbursable under the Policy
(Hospital / TPA will guide in this).
• Leave the original discharge summary & other investigations reports with
the hospital. Retain a Xerox copy for records.
December 2006
Cashless Claims - Procedures for Planned hospitalisation
Coordinate with hospital & send in all the details along with the Pre-Authorisation
Form at least 2 days prior to the hospitalisation including the plan of treatment,
cost estimates etc. to TPA.
 If “Cashless Service” is authorised by TPA
• At the time of admission, handover in the authorisation letter of TPA for
cashless service & a photocopy of ID card to the hospital.
• At the time of discharge
a. Verify the bills and sign on all the bills.
b. Pay only for those items that are not reimbursable under the Policy.
c. Leave the original discharge summary, other reports with the hospital.
Retain a Xerox copy for records.
December 2006
fast forward
better living
December 2006
Thank you
December 2006
December 2006