Insurance company :

Plan helath policy for insured

Appoint tpa to process claim

Insured :

Takes health policy from insurance company

Avail cashless benefits during hospitalisation

Third party administrator :

Process cashless claim

Empannel hospital to provide cashless service

Hospital :

Provide medical services

Provide necessary medical information to tpa for

• Tpa cell

• All assistance is provided for policy holder.

• Dedicated staffs to help you.

What is tpa?

Third party was introduced through the notification on tpa health services regulations 2001 by i.r.d.a. the basic role is to function as an intermediary between insured and insurer and facilitate cashless service of insurance.

Tpa’s attached with cmri

• Family health plan limited

• Paramount

• Ttk

• Medi assist india private limited

• Medicare

• Medsave

• Md india

• United health care

• Genins(k.p. employee only)

• Raksha

• Park mediclaim

• Allianz bajaj

• E medite
  

Cashless hospitalization

• The essence of cashless hospitalization is that the insured individual need not make an upfront payment to the hospital at the time of admission.

• Cashless authorisation has to be taken after admission to avail cashless.

• If the case is denied by the tpa’s the payment has to be made by the insured as per the hospital rules and regulation.
  

Hospitalisation

Planned hospitalization

• This happens when you have ample time to plan your admission to the hospital. For example, if the doctor advises surgery for hernia and says that you can undergo the surgery anytime in this month, it gives you time to plan you surgery.

• In such cases, it is prudent to send the preauthorization request to the tpa’s before your planned admission. This will ensure a hassle-free admission procedure for you at the hospital.
  

Cashless admission

• checks the cashless card

• if the tpa card is not available then checks the policy paper.
  

• verifies the expiry date

• identifies the tpa

• admitt under concerned tpa

• instruct to visit the tpa desk
  for further assistance
  

Know the denial

• Everything and anything is not covered. Please do your due diligence before opting for a policy.

• Go through the list of exclusions in detail. You don't want any rude shocks later.

• Any sickness or disease that you had before you took the policy will not be covered. These are known as pre-existing illnesses.

• Some insurers specify they will not cover obesity related illnesses, expenses related to terrorist acts or war or riots.

• Expenses arising from hiv or aids, use of alcohol or drugs, or a suicide attempt are never covered.

• Certain ailments like sinusitis, ulcers or cataract may not be covered initially -- say, in the first year or so of the policy. While in the first month or so, nothing may be covered except accidents.