How your media claims are processed – Direct or TPA

All Health Insurance Policy Holders face a challenge when they need claim processing. If you have a good agent then it becomes 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 the story is not the same in smaller towns or other hospitals.

All need to understand how an insurance claim is processed. There are two systems of Claim Processing :
1. Third-Party Administration: There are 26 TPAs in India that 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 fee from Insurance Companies. Though they work in close coordination with Insurance Companies paper processing is done within strict guidelines without any exception or customer orientation. As a Business Processing unit, their objective remains quality output to Insurers which is acceptable on all parameters. On the basis of the document submitted, the Insurer is able to offer a 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 privatization, 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 Systems. But the Direct system has a limited network. All Insurance companies offering Direct systems use it as superior customer orientation due to flexibility, TAT and decision making.Both systems are good. If you are living in big cities then the Direct system may expedite the decision process but in other cities, TPAs have a far superior network to expedite claim processing.

Steps to be followed by Policyholders :

First, keep your Policy Document and membership cards at a place where it can be accessed by all. Know Policy details like the sum assured, exclusions, deductibles.Please share Policy details at Hospital and discuss all details including room rent. Please note all expenses are linked to the type of room category.

While taking admission, give all history but be specific on period, medication. We get complaints that the case has been rejected because attending Doctor wrote a history of three years rather than three months. Check what has been mentioned in the Admission Papers before applying the approval request.
All good hospitals have an Insurance help desk and you need to submit your ID like Aadhar / Photograph/PAN card on an application form provided by Hospital.
This form needs a signature of attending Doctor who mentions the diagnosis, estimated cost.

Your papers are sent to TPAs / Direct Insurer and they give their decision within a TAT of 3 hours.

If your cashless is not approved then you can demand reasons and submit all documents for reimbursement.

Please ensure your claim is optimized as per policy terms. You must also claim your Pre and Post medical treatment expenses as per the limit prescribed in your policy.

Today, help is provided through companies like Insurance Samadhan who ensures that your insurance claim is maximized through proper documentation by studying Policy terms and conditions.