How your mediclaims are processed – Direct or TPA

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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  at hospitals .

In big network hospitals , you may find trained staff to guide you but story is not same in smaller towns or other hospitals .

All need to understand that how claim are processed . There are two system of Claim Processing :

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  . All PSUs like Oriental / New India/ National  operate through TPAs only

2. Direct System :  Since 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 .

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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 .

Steps to be followed by Policy holders :

  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 .
  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.  
  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 .
  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 .
  5. This form need a signature of attending Doctor who mentions the diagnosis , estimated cost .
  6. Your papers are sent to TPAs / Direct Insurer and they give their decision within a TAT of 3 hour .
  7. If your cash less is not approved then you can demand reasons and submit all documents for reimbursement .
  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 .

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 .

Shailesh Kumar

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