Home | Branch Locations | Contact Us

IRDA License No. 16

What is Domiciliary Hospitalisation?

Domiciliary Hospitalisation is a state where a person/patient is unwell that he/she requires medical attention at home itself because he/she is not in a position to go the hospital or there is no Place in the Hospital. Upon, Doctor certification stating the patient's position, the Patient becomes eligible for a claim under Mediclaim for Treatment at home.

What do you mean by Family Floater?

Family floater is a privilege offered to the client only in case he opts for "Group Mediclaim Policy". Unlike in an Individual policy, where a family (Husband/Wife) is covered for the Sum Assured so desired, independent of each other, and pays the premium accordingly, in a Family Floater-The employees family is covered for a fixed amount and anyone in the family can avail/Advantage till the limit is exhausted. The premium payable is calculated on the employee's age and a 20% loading in charged for every added person of the employees' family. .

What sort of Hospitalisation will not get covered?

1.) Hospitalisation should be at least for 24 hrs.
2.) Hospital where the treatment is done should be a reputed hospital, having at least 15 beds, an emergency unit (24 hrs open) and a separate Operation Theatre. 3.) There are certain exceptions in the nine months waiting period is there for maternity cases. Few diseases are not getting covered like Cataract, BPH in first year. Pre-existing will not get covered/ninth month, and first years

Also see 'Policy Information & Exclusions' available in your login home page.

What is Cashless access?

Till recently the Mediclaim policyholders had to pay the hospital for treatment and then send the bills to the insurance company for reimbursement. Henceforth, the insured will not have to pay the network hospitals after undergoing treatment. He will have to sign the bills and we will pay the hospital for the treatment undertaken by the insured (subject to Policy Terms, exclusions and Conditions).

How does Cashless access work?

Each person covered under the Policy will be issued an identity card. Whenever there is a need for hospitalisation the policyholder should obtain an Authorization Letter from TTK. The authorization letter will indicate the name of the insured/patient, the name of the hospital where treatment is required, the nature of illness/ disease for which treatment is required and the monetary limit above which the insured/ patient will have to pay. The policyholder will have to submit this authorization letter along with the identity card given by TTK to the admission counter in the hospital. The hospital will then start treatment.

How does one obtain the Authorization letter?

The policyholder is required to fill the request for authorization or pre- authorization letter and send it to the nearest TTK office mentioned in this booklet/ web site. Additional copies of the Pre-Authorization letter can be obtained from any of the TTK offices given or you could download the same from the site. TTK will scrutinize the request for authorization letter and send an authorization letter or regret letter.

Can a request for Authorization for cashless be declined?

Yes, a request for authorization for cash less access may be declined if,

• Inadequate/vague/wrong information is provided and the TPA is unable to get access to further information.
• The ailment/ disease for which hospitalisation is required is not covered by insurance.
• The person does not have adequate insured amount left to cover the hospitalisation costs.

This only means that cashless access is declined, AND IS IN NO WAY TO BE CONSTRUED AS DENIAL OF TREATMENT. The policyholder must obtain the treatment as per his/ her treating doctors advice.

The denial of pre-authorization letter shall not be construed to mean that the policyholder cannot claim under the terms, exclusions and conditions of the policy from TTK. In such cases you are advised to file your claim for reimbursement and TTK will settle the claim as per your policy terms and conditions.

How does hospitalisation for Planned Hospitalisation work?

a) The request for Authorization (Pre- Authorization) for planned treatment has to be filled up. This form has to be filled up by the Doctor recommending Hospitalisation. The form must be filled fully in Block letters indicating the Doctors Name, Registration Number and Telephone Phone number. Should our Medical Officer need any clarification he may contact your doctor before he initiates action on your request.
b) This request must reach TTK office at least 4 days before hospitalisation.
c) Any change in the date of hospitalisation, Hospital, nature of illness or surgeon who is going to perform the procedure will make the authorization invalid. A fresh authorization will have to be taken.
d) The authorization is valid only for Network Hospitals.
e) The authorization will be addressed to the hospital and sent to the patients address or faxed to the hospital as desired by the policyholder.
f) A claim form must be collected from the nearest TTK / Insurance office or you could download the same from the site.

What are the points one must note while Getting Hospitalised under cashless access scheme?

In order to secure admission on the appointed day, you are advised to register your name with the hospital well in advance.

• Contact the admission desk of the Hospital / TTK Branch office
• Show your TTK identity card and the Authorization letter given by TTK. The hospital will check the ID card and authorization letter.
• Some network Hospitals may charge you registration fees/ admission fees etc. These will have to be paid by the policyholder. These expenses are not reimbursable under your policy.
• In case the amount approved is less than the estimate given by the hospital you may be required to make arrangements for the difference. In addition to the above, you will also have to pay expenses towards telephone charges, ambulance charges etc. In case you wish to know more on expenses that is not covered by your policy please contact us on our toll free number for clarifications.
• Get admitted.

How does Emergency Hospitalisation under cashless access scheme work?

The policyholder is advised to get admitted immediately.

In case of admission to a Network Hospital the hospital will admit the patient as per the procedure of the hospital.

The hospital will then contact TTK and send us a request for authorization. At times the policyholder relative may be required to contact TTK for clarification.

The policyholder/relative must send the pre-authorization request completely filled. TTK will revert within 6 hours of receipt of the request.

If the authorisation is given, the policyholder may
1. pay for the non-medical expenses before leaving the hospital
2. sign on relevant documents which will be sent to TTK by the hospital

In case cashless access is declined, this is in no way to be construed to be denial of treatment The policyholder must obtain the treatment as per his/ her treating doctors advice. The denial of pre-authorization letter shall not be construed to mean that the policyholder cannot claim under the terms and conditions of the policy from TTK.

In such cases you are advised to file your claim for reimbursement and TTK will settle the claim as per your policy terms and conditions.

In case the policyholder gets admitted to a non-network hospital then the hospitalisation bills will be reimbursed subject to Terms, exclusions, Conditions and limitations of your Policy.

How does Billing and discharge under cashless access scheme work?

• Sign the final bill and check the bill for correctness. TTK reserves its right of recovery of any amount due to it from the insured person for billed services, which are not covered by the policy.
• Ensure that all supporting documents are attached to the bill.
• You must pay all bills not associated with the condition for which hospitalisation was authorized and the amounts in excess of the approved limit.
• Retain a copy of the final bill and discharge summary.
• Sign a claim form filled in all respects and give it to the hospital along with other authorization letter given by TTK before discharge.

Also see 'CASHLESS PROCEDURES'

How does one get Reimbursement for pre and post hospitalisation expenses under this scheme?

The Mediclaim Policy allows reimbursement of medical expenses incurred towards the ailment/ disease for which hospitalisation was necessitated prior to hospitalisation and up to a certain number of days after discharge.

This is subject to the limits as described in the policy. The medical expenses incurred prior to Hospitalisation are called pre- hospitalisation expenses and those incurred subsequent to discharge as post Hospitalisation expenses.

Send all bills in original with supporting documents along with a copy of the discharge summary and a copy of the authorization letter to the nearest TTK Office. TTK will scrutinize the claim and settle the bills subject to the overall limit of the policy. The bills must be sent to TTK within 7 days from the date of completion of treatment.

How does one get Reimbursements in case of treatment in non- network hospitals?

Cashless Hospitalisation is available only in Network Hospitals. While it's recommended that you choose a network hospital you are at liberty to choose a non-network hospital also. In case you avail of treatment in a Non Network hospital, TTK will reimburse you the amount of bills subject to the policy taken by the policyholder.

The Policy Holders attention is drawn to the definition of Hospital in the Mediclaim policy. TTK should be contacted within 7 days from the time of admission with details of TTK card number, nature of illness, name & address of the Hospital/ Nursing Home/ Clinic, attending Doctor, Bed Number etc. The claim form can be collected from the nearest branch of the Insurance company / TTK office. This claim form must be filled fully and sent to the nearest TTK office along with the following documents in original.

• Hospital Bill with Receipt for payment along with the break up signed by the member.
• In case of surgeons / consultants bills, kindly insist on a stamped, preferably numbered receipt.
• Doctors prescription and medicine bills.
• Discharge summary sheet from the hospital.
• Pathological reports and other investigation reports along with the doctor's authorization.
• Other relevant details and documents connected to hospitalisation.

Note: Only expenses relating to hospitalisation will be reimbursed as per the policy taken. All non-medical expenses will not be reimbursed.

Also see 'CLAIM SETTLEMENT FLOWCHART'