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Sanjeev Sharma, a middle-aged man, who maintains a healthy lifestyle, one day felt a severe pain in his abdomen. Immediately, he was rushed to a nearby hospital, where he was admitted and kept under observation for a day. Doctors reported that the patient has kidney stones, which can be treated by medicine, however, he needs to be kept under observation for 24 hours.

As per the doctor’s advice, he spent the night in the hospital and started taking medication prescribed by the doctor. His wife paid the hospital bills and other expenses related to the hospitalisation, but later when they registered a claim with the insurance company, the claim was not accepted. The insurance company said that hospitalisation was not necessary at all for his condition.

Later on, when a complaint was registered with the insurance ombudsman, the decision came in favour of the policyholder, based on the doctor’s report, which said that the patient needed medical supervision. Situations like these put additional and unwarranted pressure on policyholders and their family members.

Emergency definition:

Insurance companies generally categorise emergencies as medical and surgical. Surgical emergencies are generally accident cases and trauma. In addition, surgical emergency may include other surgical problems like acute abdominal pain or dislocation of a joint and any other problem where an emergency surgery is required to stabilise the patient. For example, rupture of an infected appendix.

Medical emergencies commonly include heart-related emergencies, brain stroke, asthma, epilepsy, seizures, complications from high blood pressure or blood sugar. “Accidental hospitalisation is covered under all health insurance policies. There is generally no waiting period for accident cases. Hence, there is very little chance of authorisation being denied in the presence of a valid policy and insurance limit available,” said Sanjay Datta, head of underwriting and claims of ICICI Lombard General Insurance.

TPAs:

The normal processing time for cashless treatment for non-emergency cases is three to four hours from the time of receipt of complete information from the hospital. But to expedite the entire process, insurers and third-party administrators (TPAs) request the network hospitals to inform them as soon as a patient is admitted.

The contact number of TPAs and helpline number of insurers are mentioned on policy documents and the policyholder needs to coordinate with the hospital to have the details sent to the TPA for authorisation of cashless service. On discharge, the policyholder needs to verify and sign the bills and pay for the items that are not covered under the health policy. The policy document contains all the details about the expenses that are payable under the policy. The original discharge summary and other investigation reports should be handed over to the hospital. However, a policyholder must retain a copy for records.

In case a policyholder goes to a non-network hospital (where policyholder cannot avail cashless facility) for an emergency situation, the policyholder has to register a claim with the TPA within seven days of discharge. For emergency conditions, policyholders are asked to pay a nominal deposit as per the norms of the treating hospital, which may differ from one hospital to another.

But if the hospitalisation is planned, then the insured person is advised to fax the pre- authorisation request form, in advance, at least 48 hours prior to admission. “Industry experience is suggestive that 70 to 80 per cent of admissions are planned hospitalisations, but, still, 90 per cent of policyholders are informing TPAs only on the day of admission,” said Mukesh Kumar, head of strategic planning group, human resources and marketing at HDFC Ergo General Insurance.