A health insurance policy provides financial support to meet the expenses regarding hospitalisation or treatment. The policy can be either a mediclaim policy or a fixed benefit one. In the former case, the bills are paid for hospitalisation, while in the latter case, a fixed amount is given for treatment of certain critical illnesses. Under mediclaim policy, TPA and PPN are two important aspects for cashless claims.
What is TPA and PPN?
Third Party Administrator (TPA): It is an intermediary company between an insured and the insurer or the insurance company. Approved by the Insurance Regulatory and Development Authority of India (IRDAI),
it helps the insured in getting cashless claims for hospitalisation under mediclaim policy.
Preferred Provider Network (PPN): For some hospitals, the health care charges for health insurance policyholders are quite higher than the reasonable rate of treatment. Keeping this in mind, insurance companies have a Preferred Provider Network (PPN) of hospitals which agree to work at rationalised rates for specific procedures.
Types of Claim Settlement Process
A health insurance claim can be settled in 2 ways – cashless and reimbursement.
- Cashless claims: In case of cashless claim settlement procedure, the insurance company directly settles your medical bills with the hospital with the help of TPA. However, most health insurance plans provide this facility provided you avail treatment at a hospital under PPN.
- Reimbursement claims: Under the reimbursement process, the insured gets admitted to a network hospital (PPN) and pays the hospital bills. On discharge, the insured submits the copy of the invoice and other supporting documents to the insurance company, which reimburses the amount, if approved.
Documents Required for Claim Process
Following are some of the documents to be submitted to avail cashless claim facility:
- Duly filled in pre-authorisation form
- Photocopy of your policy copy
- Medical reports
- Test reports
- Hospitalisation invoice
- Any other document, as per the case
How to Avail Cashless Claim Facility
The process to avail the facility is:
- Once you buy a health insurance policy, you will be issued a TPA ID card
- Cashless hospitalisation can only be availed at network hospitals under the insurance company
- Get the authorisation form from the hospital help desk and fill the form with your details and resubmit it to the TPA. They will later place guarantee to the hospital
- In case your form is rejected by the TPA, you can go ahead with the treatment, settle the hospital bills and later submit the claim form for reimbursement
- TPA will process the request and evaluate the documents and settle the claim accordingly
The policyholder should keep the following points in mind to ensure a smooth cashless claim process:
- Check out the list of PPN hospitals in advance and always get admitted to a network hospital for cashless claim settlement
- It is important to submit pre-authorisation form to the TPA in a specified time frame if it’s a planned hospitalisation. In case of an emergency hospitalisation, the same can be done within 24 hours of being hospitalised
- Health insurance plans come with various exclusions for which the claims are not entertained. These are mentioned in the policy wordings. Before raising a claim, always check the exclusions for your plan
- Denial of pre-authorisation request doesn’t mean denial of treatment or coverage
Q1. Can the TPA card be used for outpatient treatment?
No, the TPA card is used in case of hospitalisation under mediclaim policy. It helps in getting cashless claims. However, outpatient expenses will be covered if it involves hospitalisation.
Q2. Will the policy be affected in case of a change in the name of the policyholder?
Inform the insurance company about the change in the name of the policyholder, or you might face a problem in case of a need of a claim.
Q3. What is a health card?
A health card is given at the time of buying a health insurance policy. The card helps in getting cashless hospitalisation facility at a network hospital. A health card provides TPA’s contact numbers and contact details.
Q4. How will a change in the treatment during hospitalisation affect the claim process?
In case of a change in the treatment procedure during hospitalization, the network hospital should submit a fresh authorization letter to the insurance company.
Q5. Does the list for network hospitals under PPN change?
Yes, the insurance company might include or omit certain hospitals from their PPN. So, check the updated list of PPN hospitals before hospitalisation.