{"id":815,"date":"2020-10-12T16:27:49","date_gmt":"2020-10-12T16:27:49","guid":{"rendered":"http:\/\/blog.insurancesamadhan.com\/?p=815"},"modified":"2024-09-30T17:35:13","modified_gmt":"2024-09-30T12:05:13","slug":"how-your-mediclaims-are-processed-direct-or-tpa","status":"publish","type":"post","link":"http:\/\/www.insurancesamadhan.com\/blog\/how-your-mediclaims-are-processed-direct-or-tpa\/","title":{"rendered":"How your mediclaims are processed \u2013 Direct or TPA"},"content":{"rendered":"\r\n

All Health Insurance Policy Holders face challenge when they need claim processing . If you have a good agent then it become their duty to guide for all support but in most cases the claimant has to go through the support help desk \u00a0at hospitals .<\/p>\r\n\r\n\r\n\r\n

In big network hospitals , you may find trained staff to guide you but story is not same in smaller towns or other hospitals .<\/p>\r\n\r\n\r\n\r\n

All need to understand that how claim are processed . There are two system of Claim Processing :<\/p>\r\n\r\n\r\n\r\n

1. Third Party Administration : There are 26 TPAs in India who are regulated by IRDA . These companies work as per guidelines provided by Health Insurers . Claims are received at TPAs , they process the same and send to Health Insurer for acceptance \/ rejection or reimbursement . For such processing of documents , TPAs charge a fees from Insurance Companies . Though they work in close coordination with Insurance Companies but paper processing is done within strict guidelines without any exception or customer orientation . As Business Processing unit , their objective remain quality output to Insurers which is acceptable on all parameters . On the basis of document submitted , Insurer are able to offer decision . As these TPAs work under strict TATs and quality audits hence they are reluctant to take any chances . However , TPAs offer much bigger Hospital Network across India for cashless facility \u00a0. All PSUs like Oriental \/ New India\/ National \u00a0operate through TPAs only<\/p>\r\n\r\n\r\n\r\n

2. Direct System : \u00a0Since privatisation, Health Insurance Providers have developed an in house claim processing system where claim documentation is done . They claim faster resolution and shorter TAT . Today companies like Max Bupa \/ HDFC Ergo \/ Bajaj Allianz \/ Star and Religare are offering Direct System . But Direct system has limited network. All Insurance Company offering Direct System use it as superior customer orientation due to flexibility , TAT and decision making .<\/p>\r\n\r\n\r\n\r\n

Both systems are good . If you are living in big cities then Direct system may expedite decision process but in other cities TPAs has far superior network to expedite claim processing .<\/p>\r\n\r\n\r\n\r\n

Steps to be followed by Policy holders :<\/p>\r\n\r\n\r\n\r\n

    \r\n
  1. First keep your Policy Document and membership cards at a place where it can be accessed by all . Know Policy details like sum assured , exclusions , deductibles .<\/li>\r\n
  2. Please share Policy details at Hospital and discuss all details including room rent . Please note all expenses are linked to type of room category. \u00a0<\/li>\r\n
  3. While taking admission , give all history but be specific on period , medication . We get complaints that case has been rejected because attending Doctor wrote history of three year rather three months . Check what has been mentioned in the Admission Papers before applying approval request .<\/li>\r\n
  4. All good hospitals have a Insurance help desk and you need to submit your ID like Aadhar \/ Photograph\/ PAN card on an application form provided by Hospital .<\/li>\r\n
  5. This form need a signature of attending Doctor who mentions the diagnosis , estimated cost .<\/li>\r\n
  6. Your papers are sent to TPAs \/ Direct Insurer and they give their decision within a TAT of 3 hour .<\/li>\r\n
  7. If your cash less is not approved then you can demand reasons and submit all documents for reimbursement .<\/li>\r\n
  8. Please ensure your claim is optimised as per policy terms . You must also claim your Pre and Post medical treatment expense as per limit prescribed in your policy .<\/li>\r\n<\/ol>\r\n\r\n\r\n\r\n

    Today , help is provided through companies like Insurance Samadhan who ensures that your claim is maximised through proper documentation by studying Policy terms and conditions .<\/p>\r\n","protected":false},"excerpt":{"rendered":"

    All Health Insurance Policy Holders face challenge when they need claim processing . If you have a good agent then it become their duty to guide for all support but in most cases the claimant has to go through the… Continue Reading →<\/span><\/a><\/p>\n","protected":false},"author":4,"featured_media":816,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_uag_custom_page_level_css":"","footnotes":""},"categories":[1],"tags":[],"class_list":["post-815","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-uncategorized"],"yoast_head":"\nUnderstanding Mediclaim Processing: Direct vs TPA Explained<\/title>\n<meta name=\"description\" content=\"Learn how your mediclaim is processed\u2014understand the differences between direct processing and TPA to make informed healthcare decisions.\" \/>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" 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