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Dr. K. Vijaya Laxmi
Health care visionary and founder of Vijaya Health Care
Empanelled FAQ

Do all health insurance policies offer cashless hospitalization facility?

No, not every healthcare Insurance policy offers cashless hospitalization. Your policy is routed through a third party administrator. Network hospitals may be defined as those hospitals which allow for cashless hospitalization based on certain conditions. When you are admitted in a non network hospital you will need to submit your bills to the hospital and seek reimbursement through TPA.

Does cashless hospitalization mean I can just walk into a hospital and get admitted for treatment free of cost?

Cashless treatment is misunderstood as free treatment. This is not the case as the insurance company will bear the cost of the treatment depending on the medical treatment which has been given. Mediators ensure that cashless hospitalization is performed quickly and easily and ensures that all bills are submitted and paid by the insurance company on time. There are very strict protocols which need to be followed which are laid down by the IRDA(Insurance Regulatory and development authority)

What procedures should I follow to avail the facility of cashless hospitalization at Vijaya Health Care?

Planned Admission

In case of a planned admission, you can avail of various types of facilities which are planned and executed well in advance. Planned admissions must be fixed with your TPA well in advance with a minimum buffer of 4-5 days and this ensures that every aspect of the insurance claim is processed completly and perfectly. We request you to achieve pre-authorization for your insurance claims and contact our reception desk. While we process the TPA claims and forward them to the third party insurers, we cannot gaurentee that the claim will be processed perfectly.

The pre-authorization procedure is detailed below:

  • Contact a network hospital.
  • Present the cashless insurance card
  • Submit the pre-authorization forms which are required by the TPA
  • Every pre authorization section is divided into two halfs these contain the general details on the health insurance policy and the treatment which is suggested by the duty doctor and this must be only filled by the medical practioner.
  • Once the TPA form is filled, we will arrange to send it and fax it to the specified third party assurer.
  • We will revert back to you with the approval or denial status

Emergency Hospitalization:

In case of emergency hospitalization, the Reception will take up your case on a fast track basis with your TPA and is likely to receive approvals within 6 hours during any working day. For cashless treatment it is mandatory for the hospital to have an approval from your TPA. In case of delay in receiving the approval or when you cannot wait for receiving the approval owing to medical urgency you can undergo the treatment by paying the necessary cash deposit. If you receive approval from your TPA, you are entitled for refund of the cash deposit.

What do I do if I do not get approval on my cost of treatment till the time of discharge at the hospital?

Cashless hospitalization is linked to the approval of the estimated expenditure on your proposed treatment. In case you do not get your approval you will need to bear the entire expenditure incurred on the treatment. Therefore it is always prudent to get approval and then get yourself admitted. You could explain to your doctor the benefits of getting approval before the date of admission as also when he recommends immediate admission.

Vijaya Health Care will not entertain any request for a refund of the amount paid if the approval comes after the process for your discharge has been completed.

Under what circumstances will the request for cashless hospitalization not be entertained?

Normally your request for approval might be rejected when:

  • Information contained in the pre-authorization form is insufficient for the TPA to arrive at a decision and further information is not available for various reasons. However the chances of rejection under this criterion are rare since the Reception at the hospital is experienced in complying with pre-authorization formalities and will advise you suitably.
  • The ailment for which hospitalization is being sought by you is not covered under your insurance policy for reasons like pre-existing ailment, specific exclusions (accident admission under the influence of alcohol or drugs).
  • You have exhausted your eligible medical insurance cover for the year.

What do I do if the actual medical expenses overshoot the pre-approved amount?

In case your hospitalization expenses exceed the pre-approved amount, you can approach the Reception to apply for an enhancement of the pre-approved amount. The Reception will apply for an enhancement on your behalf with the TPA and provide the necessary documentation. In case you have not exhausted your medical insurance limit, it is most likely that your TPA will approve the application for the enhancement – either for the requested enhanced amount or up to your insured limit after deducting the value already utilized by you during the year – whichever is less.

If the TPA turns down the request for enhancement you will need to pay the amount incurred in excess of your approved amount directly to the hospital before discharge

Does cashless hospitalization cover all medical expenses?

Do all health insurance policies offer cashless hospitalization facility?

For complete details on the medical expenses that are covered, and those that are not covered, you need to go through your health insurance policy. However, in general, the expenses listed below are not reimbursable under cashless hospitalization

  • Registration / Admission fee
  • Telephone charges
  • Visitor / Attender charges
  • Ambulance charges
  • Charges for diet, which is not part of the administered treatment
  • Document charges
  • Toiletries
  • Non-medical expenses
  • Service charges
  • Room charges not eligible for
  • The List of disposables that are not covered is available with the reception

These need to be paid by you directly to the hospital at the time of discharge

In case of cashless hospitalization, what are the documents the hospital requires from me at the time of discharge?

All the original documents including bills, lab reports, discharge summary and claim form. All the original documents duly signed by you need to be submitted to the hospital.

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