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Quick Reference

Given below are a few frequently used terms pertaining to medical insurance that you need to be familiar with.

Cashless Access

A special benefit extended by an insurer or by the assigned TPA for availing medical treatment as an inpatient without the necessity to pay the treatment costs upfront to the hospital. Under this procedure the payment due to the hospital will be met out either by the insurer or by the assigned TPA. After discharge, the hospital sends the bills pertaining to medical expenses to the Insurer /TPA, (subject to insurance policy and conditions) for reimbursement. The hospital can claim in accordance with the preauthorized limit and additional cost as envisaged by the enhancement. In any case the upper limit of this facility cannot exceed the sum insured under the contract of insurance.

Denial

Repudiation of a pre Authorization request /admission liability/cashless facility and or settlement of a claim under the insurance contract.

Discrepancies

Any difference between the amount claimed and admissible amount and also any violation of terms & conditions of the insurance policy or agreement.

Domiciliary Hospitalization

Medical treatment for a period exceeding 3 days for such illness/diseases/injury which in the normal course would require care and treatment at a hospital but is actually taken whilst confined to home under certain circumstances (where the patient cannot be moved to the hospital or due to lack of accommodation – as per the definition of insurance policy)

Enhancement

A situation when an insurer seeks to increase the limit of the authorized claim amount resulting from extension of hospitalization.

Exclusions

The items that are specifically and expressly removed from the scope of the insurance contract and hence are not payable.

Hospitalization

Medical treatment after getting admitted in a hospital.

Insured Amount

The maximum limit up to which the insured can seek medical treatment under that mediclaim policy.

Insured/Policy Holder

An insured or policy holder is a person who is eligible to receive the insurance benefit from the policy which they have applied for.

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