Insurance and TPA

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 up front 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 the discharge from the hospital the bills pertaining to medical expenses incurred at the hospital, are sent to the Insurer/TPA, (subject to insurance policy and conditions) for reimbursement by the hospital. The hospital can claim in accordance to the pre authorised 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 authorisation 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 Hospitalisation
Medical treatment for 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 at 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 insurer seeks to increase the limit of the authorized claim amount resulting from extension of hospitalisation.

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

Hospitalisation
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
Individual, who by paying a premium, secures himself to receive medical treatment up to a fixed sum of money in the event of injury, loss or damage to his body.

Insurer
A corporate body licensed by IRDA for underwriting various insurable risks against any or all insurable perils with an assurance to make good the loss in an unforeseen eventuality.

IRDA
Insurance regulatory & development authority, a body constituted under the ministry of finance to deal with licensing, regulating and monitoring all activities relating to the insurers, brokers, agents, corporate agents and the TPA’s.

Limitations
Restrictions in the operative clause of the insurance contract to the limit of benefits, use etc.

Mediclaim Card
A card issued by your TPA with a primary purpose of identification. This contains the policy number, name and validity period. Many of the TPA’s prefer to place insured’s photograph & signature to improve its authenticity. Though it is being popularised as a cashless card, it serves only as a means to avail cashless benefit subject to the terms & conditions of the policy.

Mediclaim Policy
An insurance policy that covers hospitalisation expenses incurred during an inpatient hospitalisation. Please check terms and conditions of the policy to understand the nature and the scope of risk covered.

Medico Legal Case
A situation arising out of treatment at the hospital for any bodily injuries sustained in an accident or an attempt of suicide, which needs to be intimated to the police and other concerned authorities for any investigation and procedures. For example burns, suicide, road traffic accident, assault, etc.

Network Hospital
A hospital which has entered into an agreement/MOU with an insurer or a TPA to request pre authorisation, extend cashless facility and accept payment at a later date on submission of bill complying to the policy requirements. Those hospitals who do not have a prior agreement for cashless hospitalisation with your insurer/TPA are called non-network hospitals.

Planned Hospitalisation
Taking advantage of the medical condition where one does not require immediate hospitalisation (as it would not affect his quality of life in any way), the insured seeks pre authorisation sufficiently in advance of actual admission in the hospital for treatment on cashless basis.

Policy Terms & Conditions
Terms and conditions outlining the details and the limitations of the insurance contract indicating the requirements for fulfilling or adhering to the contract of the insurance.

Pre Authorisation
Authorisation issued by the insurer or by the assigned TPA for admission and treatment up to a value as deemed fit by the insurer, for treatment by the hospital. To receive pre authorisation one has to make a request providing the details contained in the pre authorisation Form.

Query
Clarification requested to dispel any doubt pertaining to the line of treatment and the contract of insurance.

Reimbursement
A facility under which the insured can claim the expenses borne by him during hospitalisation which is otherwise claimable under his insurance contract.

Toll Free Number
A telephone number (calls to which are not charged) provided by your insurer/TPA to get in touch with them for any clarification.

TPA
A corporate body licensed by IRDA for processing and setting on their behalf, claims arising under medical insurance policies and to coordinate with hospitals for all relevant and related processes.