Topic 4: The Importance of Network Hospitals in Health Insurance

India’s COVID-19 count continues to rise with the total number rising above 9 million. The deadly virus has till now claimed over 1.3 lakh lives throughout the country, and the toll rises with each passing day. Considering the ongoing pandemic situation, it is imperative to have a comprehensive health insurance policy that can help you avail the best treatment possible at a hospital of your choice, without burning a hole in your pocket. Your comprehensive health insurance policy will not only provide you adequate coverage against the novel coronavirus (COVID-19), but will also cover you for all other illnesses and ailments such as cancer, stroke and diabetes. With your health insurance policy, you can not only avail quality healthcare, but also have the benefit of availing cashless treatment at your choice of network hospital. What this essentially means for the customer is that during hospitalisation, you can avail cashless treatment – without paying anything to the hospital – at your choice of network hospital.

What is a network hospital?

When you buy a comprehensive health insurance policy from your choice of insurer, you get a list of hospitals under the name of Network Hospitals. Apart from the policy documents, you can find this list on the website of the insurer as well. All hospitals mentioned in this list allow policyholders to avail cashless treatment at their centre. This means, the policyholder does not have to pay anything at the hospital for taking treatment, apart from nominal file charges items / expenses excluded under policy condition and IRDA regulations. The biggest benefit of availing treatment at a network hospital is that the insured does has to run to different places in order to make financial arrangements and all expenses are borne by the insurer. The insurer directly settles the bill with the hospital without you paying any amount, provided the treatment is taken as per the policy terms and conditions.

Making a cashless claim in a network hospital

When you file for a cashless claim at a network hospital, there are usually three major entities involved – the insurance company, the hospital and the insured person. You can file an insurance claim under two categories – Planned Hospitalisation and Unplanned Hospitalisation (Emergency). In a planned hospitalisation, both the insurer and the network hospital are informed about the hospitalisation of the insured beforehand. As a process, before availing the treatment, the insured or the family members need to fill a pre-authorization form to get the person admitted. You can download the pre-authorization form from the insurer’s website; it may even be available at the hospital’s TPA counter. A TPA counter is a dedicated kiosk at the hospital premises where all the insurance-related queries and processes of the insurers are addressed. Once the pre-authorisation form is submitted, the TPA desk will verify the submitted details and will inform your insurer regarding the claim. Once the insurer approves your claim request, an authorization letter is sent by the insurer/TPA to the hospital, stating the amount approved for the treatment. This amount is directly paid to the hospital by the insurance provider. The approximate Turn Around Time (TAT) for pre-authorized claims in the case of network hospitals is approximately 30 minutes to 2 hours. However, one must know that TAT varies from insurer to insurer.
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