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What is Hospital’s role in Mediclaim Insurance?

Mediclaim Insurance is a contract between insured (patient) and insurance company. Insurance company operates through TPA (Third part Administrator) MOU done by TPA with hospitals offering cashless services to mediclaim patients.

Hospital is only a facilitator between TPA & patient. Hospital is not responsible for approvals, objections, delays, deductions & denials for mediclaim cases. The hospital supports the patient in getting cashless facilities.

As a rule, if someone is coming for a planned admission, they should come with an authorization letter. For TPA for all emergency admission, hospital will assist in the cashless procedure.

What documents I need to submit for availing cashless facility at hospital?
  • Copy of Insurance policy – (last three years)
  • Patient Photo ID proof
  • First Consultation letter
  • Previous investigation reports (if applicable)
  • Past discharge summary (if applicable)
  • Any other documents or policy called by TPA
How much Mediclaim I am eligible for a single hospitalization under the policy?

Approval is given by TPA as per each specific policy terms and conditions.

TPA takes into consideration :

  • Previous utilization of the policy.
  • Continuity of policy
  • Any other specific terms of the policy which is known to insurer.

1 PPN Packages (Private Provider Network)

Insurance companies have fixed charges for certain treatments and is applicable to various hospitals who are part of PPN network.

Do I have to pay any cash on admission?

Yes. On admission deposit is collected from patient as per hospital Schedule of Charges.

If cashless approval is not received on before of surgery, amount due for OT clearance is to be deposited mandatorily. Deposit shall be adjusted against non admissible and any other deduction by the TPA

Will I be regularly informed about the progress of the Claim?

Yes. Hospital will update you about the status of the claim right from first approval, query clarification and final approval. Detailed information shall be available from TPA front desk.

Can I avail higher category of Accommodation which is not eligible as per my policy?

Hospital does not encourage availment of stay which patient is not entitled to as per his policy.

I have 2 policies with 2 different insurance companies for cashless. Am i eligible for cashless at the same time for a single hospitalization?

No. Only 1 policy shall be considered for cashless by the hospital. The patient has to go for reimbursement for utilization of the2nd policy.

Am I entitled to receive all clinical documents, reports, x- ray film. from the hospital?

Only photocopy of the documents shall be provided to the patient as Originals are required by the TPA for processing the claim.

How much time is required for pre authorization & discharge approval?
  • Normally TPA provide Pre authorization within 24 hours if there are no queries/objections raised.
  • For discharge approval TPA’s take approximately 6 hours.
  • Discharge information must received before 2 P.M

Hospital has no role to play in expediting the approval as powers to approve lie with TPA and Insurance company. It’s the responsibility of the patient to contact the TPA, if the authorization is not received on time.

Is cashless facilities at hospital available 24 hours 365 days a year?

The TPA front desk at hospital is open from 9.30 A.M to 19.00 P.M everyday. On weekends some of the TPA’s are not working and this might result in delay. TPA’s are not open on public holidays too.

What is the process for cashless, if admitted on a public holiday or Sunday?

Process will be done on next working day. Till process it will be considered as regular paying patient only.

Third Party Administrator (TPA)

For more details, please call (Between 10 am to 6 pm):
+91 75730 05048

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