52.    Cash Less Medi-Claim by Health Insturance Company

As the name suggests, one can get hospitalized, undergo surgery or both without having to pay cash at the time of bill settlement. The insurance company settles the bill directly through its third- party administrator (TPA) whose contacts are usually provided along with the policy. The hospital would require the patients ID card to check the policy details so as to deliver the cashless service. But this easy insurance works only under certain conditions.

Every insurer has a list of hospitals in which you can use the cashless facility. You can get this information in the insurance company’s website and cross check with the TPA. The list, however, is subject to change as hospitals frequently have disagreements with insurers and drop the cashless arrangement. If the hospital of your choice is not on the list, one can still avail of treatment there, However, one will have to pay for the treatment at the first instance and later get a reimbursement from the insurer by submitting the bills. The average time taken for reimbursing bills is 20 days.

Although the insurance policy would have been issued by some general insurance company, Third Party Administrators play an active role in cashless mediclaim. The payment usually is made by the TPAs. Most of these TPAs provide administrative support to the insurance companies for servicing their insurance policies. As far as you are concerned, TPAs are the maib contact point for settling claims. If the insurance company fails to stick to its contract, you can complain to the insurance ombudsman whose  contacts are available on the Irda website, www.irdaindia.org.

What happens if your CashLess Mediclaim gets Partly Reimbursed?

This doesn’t mean that the claim has been rejected by the insurance company. The claim has been rejected at the TPA’s end. TPAs sanction the claim amount based on a clause called “customary and reasonable charges”. They keep a database on average costs of various surgeries across cities. Based on this database, the TPA sanctions, the claim amount. Usually, a surveyor visits the hospital to validate the claim. At times, the TPA approves a part of the amount and the balance has to be borne by you. In extreme cases, the TPAs reject the claim if the surveyor is suspicious of the patient or hospital’s credibility. In such cases, one has to settle the hospital bill and take up the case with the TPAs/lnsurer later.

In case of planned surgeries, one should check the approximate bill amount with the hospital. Then, one could check with the TPA on the size of the claim amount and its likely settlement. Often, even hospitals should take an in-principle approval from theTPAto avoid last-minute hassle in the case of planned surgeries. In fact, some TPAs make it mandatory for patients/hospitals to take prior in-principle approval except in case of accident-related claims.

Note :

Medical Premium paid by an individual is eligible for deduction from the total taxable income. The maximum amount of deduction that can be availed currently is Rs. 15,000 if the policy covers self, spouse and/or dependant children and an additional Rs.15,000, if exclusively taken for dependant parents. Thus, an individual can claim a maximum of Rs. 30,000 as deduction from the total taxable income. In case Insured is a senior citizen then the deduction is Rs. 20,000. Interestingly, it the individual himself and/or his spouse are also senior citizens, they shall also be entitled to a maximum deduction of Rs. 20,000 instead of Rs. 15,000. It such an individual also pays medical premium for dependant parents, who are also senior citizens, the maximum allowable deduction for such an individual shall thus be Rs. 40,000 p.a.

An additional avenue of Rs. 5,000 is also available to cover expenses for preventive health check-ups for self and family members within the overall limit of Rs. 15,000/20,000 for Mediclaim insurance premium.
 
 
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