Medical Claim Process & TPA

As already discussed in Medical Facilities to Staff tab, every serving and retired staff of bank is covered with medical insurance policy issued by United India Insurance Company (UIIC). There are various Third Party Administrator (TPA) allotted with the policy who work as the bridge between insurer and insured and facilitate the smooth claim settlement, reimbursement, cashless facility etc. These TPAs have tie-up arrangement with popular hospital in all the cities in India. All these hospitals are called Network Hospitals. In all these hospital we can find the representative of the TPA who process our cashless claim.

The main function of TPA is to administered the the claim under the policy. These claim may be of three types:

1. Reimbursement Claim
2. Domiciliary Claim
3. Cashless Claim
4. Pre-Post Hospitalization Claim
   

Reimbursement Claim

When the hospital here the treatment is being taken by the insured or dependent is not in the list of network hospital then we have to pay all the bills out of our packet and claim the reimbursement for the same from insurer through our TPA. The process of reimbursement claim is discussed below:

1. Minimum 24hrs hospitalization is compulsory for reimbursement claim except some deceases as mentioned in Policy Document. For policy document go to Medical Facilities to Staff
2. Upon Hospitalization of Self or Dependent, We need to intimate about hospitalization to our TPA within 48 hours of Hospitalization
3. Collect all the original prescriptions with doctor's rubber stamp and signature
4. Collect all original pharmacy GST No. printed bills with stamp and signature
5. Collect all investigation reports, films like CT scan, ultra sound, X-Rays, MRI etc.
6. Collect all other payment bill like ambulance charges paid, physiotherapy charge, consultation charges, revisit charges etc.
7. At the time of discharge collect the original discharge summary
8. Download the reimbursement form from your TPA website. For PDF of claim form Click Here
   
9. There are two part of the Claim form, Part A to be filled by the insured and Part B to be filled by the Doctor/Hospital
10. Send the duly filled form to your TPA by courier or in person along with following within 30 days of discharge:

• Completed Claim Form Part (A&B)
• All Original Bills, Prescriptions, Reports, Films etc.
• Your TPA Member ID
• Claim Intimation letter received on your Email with intimation number
  
• KYC of Insured and Patient
  
• Cancelled Cheque for payment details
  

Domiciliary Reimbursement Claim

There are 65 deceases at present where we get the facility of domiciliary treatment i.e. we don't need to get hospitalized in order to get the reimbursement. Domiciliary Claims can never be cashless even in network hospitals. Therefore there we have to follow the above procedure for reimbursement. In domiciliary claim everything mentioned above holds true except:

1. There is no requirement of intimation
2. We need to complete only Part A of reimbursement form. Part B not required
3. Here first bill date will be considered admission date and last bill date will be considered discharge date
4. There is no requirement of discharge summary/card
5. Claim can be send after every visit of hospital or you can combine more than one visit and send the documents altogether in single claim form

Cashless Facility

As already mentioned above, all the TPAs have a list of Network Hospital. These network hospital provides Cashless facility to the insured. There is a TPA agent in all the hospital. We need to contact the TPA agent/representative with our TPA member ID and insurance policy number. It is advisable to carry KYC documents also just in case the need arises. After submitting our document, TPA agent will get the claim approve by its own. In this case insurer directly pays to the hospital. In case there is any disallowed expenses, these are borne by the insured. Hospitals have a policy to take some lump sum amount as deposit in all the cashless claims. If some expenses are not reimbursed by the insurer then hospital deduct those expenses from deposit amount and the balance is refunded the patient. In case of short fall, patient need to deposit the money.

Pre-Post Hospitalization

Medical policy of bank covers pre and post hospitalization expenses also. One can claim expenses incurred upto 30 days before the hospitalization and 90 days after the discharge date. Pre and Post hospitalization claims are treated as domiciliary claims and procedure to send the claim is also same. Pre and post hospitalization claim cannot be cashless, therefore we need to send the claim within 30 days of last bill date. We should also ensure to mention the main reimbursement or cashless claim number which is related to the pre and post hospitalization claim.

Reference: Policy document of BOB and Joint Notes 2015