Terms and Conditions applicable for cashless hospitalization for planned/emergency admissions & subsequent discharge
At SMH, you will find most of Third Party Administrators (TPAs) affiliated to help us extend cashless facilities to our patients. ( kindly refer list of TPAs affiliated to Spandan Hospital)
Our dedicated TPA team is always ready to support patients / relatives regarding application for Mediclaim Cashless Approval process and the documents and procedure required for initiation of cashless process with TPAs. We do so by communicating through phone, email or fax. In order to initiate procedure for cashless process, patient needs to bring 3 years of mediclaim policies with all pages. Photo ID proof is also a must (PAN card, Passport, license etc). TPA card issued by the TPA if available is also required especially in case of corporate clients.
Match your age, spelling of your Name, in the photo ID, Indoor Case Sheet with your insurance policy. Any variation in any of these can lead to cancellation/delay of cashless process.
The declaration of past medical illness & ongoing medicines has to be properly filled up in the declaration form as this would be mentioned in the AL request form. Any change in the details would not be possible by the hospital authorities later on.
We fax/mail all documents after reasonable lab and radiology reports are available and a probable diagnosis is made. This may take some hours post hospitalization as mailing the form without supportive reports is of no help. However, SMH has no role of issuing authorising letter which is solely at the description of the TPA doctor's team. Patients/ relatives have to wait for the Authorization Letter (AL) or contact insurance company/their agent by themselves to know the progress in cashless authorization by the TPA. By any means, SMH does not take any guarantee for the issuing of the AL. Sometimes, there are queries raised by the team of doctors of the TPA which have to be answered by us. This may delay the issuing of AL for cashless hospitalization.
There are cases where TPA doesn't issue AL (pre authorisation) and some applications do not get authorisation letter for cashless treatment from TPA doctor's team. ISSUING AL IS AT THE SOLE DISCRETION OF TPA DOCTOR'S TEAM AND NOT WITHIN POWERS OF HOSPITAL AND THE CONCERNED AGENT. If AL letter is not received, patient needs to pay cash in such situations,
After discharge of the patient, SMH will provide necessary documentation for the mediclaim reimbursement. Patient needs to go for reimbursement by self in such cases (guidance will be available). In some cases, the TPA doctor's team authorizes only a partial amount. The amount over and above the authorized amount needs to be paid and re-imbursed by the patient.
If SMH hasn't received authorisation letter in 24 hours, additional deposit is required to be paid on day to day basis. Patient has to pay initial deposit as per hospital terms and conditions in case of proposed cashless hospitalization, which will be considered for refund after hospital gets the payment from TPA Company.
Patient has to pay cash for buying pharmacy at SMH till approval letter is received from TPA. After receiving approval from TPA, submit bills of pharmacy at the hospital TPA office and collect refund amount at discharge time.
The cashless facility will be provided only to the extent of the approved amount as mentioned in the letter of authorization issued by the concerned TPA. It is responsibility of patient to ask for estimate of total expenses during admission or in case of pre-planned operation/hospitalization. Also the TPA may issue less or same amount. Patient has to pay differences in case of amount issued by TPA is lesser then the billed expenses.
SMH charges 10% of charge to hospital final bill as an administrative charge with 250 Rs admission fees and 100 Rs registration fees. These charges are not payable by most of TPA Companies. Further, non- medical (inadmissible) expenses or deduction amount needs to be paid by patient ( if not approved by TPA/insurance company)
In case of death, if it occurs in non working hours, relatives has to bear the entire bill of the hospital, even if initial AL has been received from insurance company as final approval cannot be obtained. Final approval is necessary as initial approved amount is cancelled at the time of obtaining final approval in some cases subject to the discretion of the TPA doctors. Hence in such cases, the patient's family has to put up the entire hospital related expenses for reimbursement.
In case of discharge, additional procedure is required to get approval for full expense incurred on the patient's hospitalization. This may take typically few hours to a day and may even take longer depending on the queries raised again by the TPA doctor team. If patient is not ready to stay, he can choose to get discharge in 2-3 working hours by paying full amount in cash for reimbursement. Claim support is available at the hospital TPA desk. Otherwise, the patient has to patiently wait for discharge till the final documents are forwarded to the TPA and final authorization letter is received from the TPA.
There is capping of room charges, visit charges, investigation, and operative charges etc depending on the limit of sum insured. If you opt for higher grade, you need to pay extra amount that is inadmissible. If it is cashless hospitalisation, these charges will be reflected in the final AL letter received from the company.
With some policies, corporates, there is Co-Payment to be made for their mediclaim expenses. The amount of Co-payment is mentioned in the AL issued by the respective TPA. The patient has to make payment accordingly.
For re-imbursement of the expenses above the cashless expenses, which are paid by the patient, kindly submit the bills with claim form to the TPA desk. They will make the file ready for reimbursement and hand over the completed file to the patient or his/her relative for re-imbursement. Patient will be given the completed file in 1-2 days depending on the circumstances.
Regardless of mode of initial payment by the patient/his relative, amount above Rs. 10,000/- would be returned by only cheque by the hospital. If the cheque given towards patient’s treatment bounces, Rs. 250/- will be changed for the cheque return from the patien/his relatives.
Due to continuous changes kindly confirm availability of TPAs/ Insurance company and terms - conditions of cashless prior to admissions at TPA desk - 09428013690/07874701
