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 upfront 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 discharge, the hospital sends the bills pertaining to medical expenses to the Insurer /TPA, (subject to insurance policy and conditions) for reimbursement. The hospital can claim in accordance with the preauthorized 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 Authorization 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 Hospitalization: Medical treatment for a 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 to 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 an insurer seeks to increase the limit of the authorized claim amount resulting from extension of hospitalization.
Exclusions: The items that are specifically and expressly removed from the scope of the insurance contract and hence are not payable.
Hospitalization: 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: An 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 insurers, brokers, agents, corporate agents and TPAs.
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 the primary purpose of identification. This contains the policy number, name and validity period. Many of the TPAs prefer to place the insured’s photograph & signature to improve its authenticity. Though it is being popularized as a cashless card, it serves only as a means to avail cashless benefit subject to the terms & conditions of the policy.
Mediclaim Policy: A insurance policy that covers hospitalization expenses incurred during an in-patient hospitalization. Please check the terms and conditions of the policy to understand the nature and scope of the 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. (Burns, Suicide, RTA, Assault).
Network Hospital: A hospital which has entered into an agreement / MOU with an insurer or a TPA to request preauthorization, extend cashless facility and accept payment at a later date on submission of bills complying with the policy requirements. Those hospitals that do not have a prior agreement for cashless hospitalization with your insurer / TPA are called non-network hospitals.
Planned Hospitalization: Taking advantage of the medical condition where one does not require immediate hospitalization (as it would not affect his quality of life in any way), the insured seeks preauthorization 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-Authorization: Authorization 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 preauthorization one has to make a request providing the details contained in the Pre-Authorization 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 hospitalization which is 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 settling claims arising under medical insurance policies and to coordinate with hospitals for all relevant and related processes.
Note: This information collated by Pragna Children’s Hospital is presented for public knowledge. It should in no way be construed as legally binding on Pragna Hospitals.
