Process Docs

What is health insurance?
Health Insurance or Medical Insurance also known as Mediclaim is a type of insurance coverage that pays for medical and surgical expenses that are incurred by the insured. Health insurance can either reimburse the insured for expenses incurred from illness or injury or pay the care provider directly.

What is a Claim?
A claim is the payment made by the insurer to the insured or claimant on the occurrence of the event specified in the contract, in return for the premiums paid for the insured.

What is LOC?
LOC is a Letter of Credit/Authorization letter issued by TPA to Network Hospital to offer credit facility to the Insured based on medical admissibility and Policy terms and conditions. It also specifies that any non-medical expenses should be collected from the Patient at the time of discharge.

What are the types of Hospitalization?

  • Planned Hospitalization
    IF YOU ARE PLANNING HOSPITALISATION, you need to do the following:
    • Fill the Pre-Authorization Form, available with the Network Hospitals. This form can also be obtained from our site.
    • Fax the Pre-Authorization Form To Medvantage office 4 days in advance
    • If your hospitalization is authorized, then ensure
      You pay for non-medical expenses
      Sign the relevant documents including a claim form before getting discharged
  • Emergency Hospitalization
    WHEN YOU NEED EMERGENCY HOSPITALISATION, please follow the guidelines and update your family members so they would know what to do-
    • Get admitted into a network immediately
    • Please inform your family member /relative to contact the billing dept in the hospital to inform UHC.
    • If your hospitalization is authorized, then ensure
      You pay for non-medical expenses and
      Sign the relevant documents including a claim form before getting discharged
    If your hospitalization is rejected, your treatment will be continued at the hospital. After discharge, you can submit your claim for reimbursement (Refer Check-list for Submission of Claim)


What parameters are considered by the company while asking the claimant to submit particular records / document?
The Company considers the Sum at risk, cause, circumstances of claim and duration of the policy while asking for certain requirements. Eg. Investigation reports, FIR / MLC in accident cases, treatment details, previous consultation papers, etc.

Once all the requirements are submitted, how much time does the Company take to settle the Claim?
The Company settles the Claim within 7 days after all the records, documents and necessary forms are submitted and documentation is completed.

In case, the Claim warrants further verification, the Company keeps the Claimant informed of the same. Subsequently, when the decision is taken, it is communicated to the Claimant by a letter. From November 2005, we have started sending SMS Alerts to the advisor of the policy to enable the quick communication of the decision of the claimants.

What does it mean by Investigation Reports?
Investigation report mean the pathological and diagnostic tests that one have undergone during the treatment on treating doctors advise. Some examples are blood tests, urine examination, X-ray, ECG, etc.

How to clarify/ justify prolong stay at the hospital?
Justification for the stay duration is required. This needs to be explained by the treating hospital and the treating doctor on their letterhead. This is asked by insurers when the duration of stay is more than the average duration of stay for a particular treatment. Please contact the hospital and obtain the same.

What does it mean by Sticker/invoice and why it is important?
A Sticker/invoice is asked to prove the charges incurred for a lens (Cataract) or any other implant like CABG, Abdominal Surgeries, Knee replacement surgeries, pace maker, prosthetic joint etc. Sticker need to be in original. Invoice is accepted in photocopy. Declaration letter authorized by hospital is required if invoice not issued containing the reason for non-issuance (Insurer specific)

What does it mean by Indoor case papers and where do we obtain these from?
A set of ICPs consists of daily progress notes, daily nursing chart and line of treatment administered. It contains all the details of the patient right from time of admission up to the time of discharge. The notes and observations made by each and every doctor during their rounds/visits and their advise.

What are the contents in Discharge Summary?

  • Summary of the entire hospitalization including diagnosis & line of treatment.
  • A legal and mandatory document. Always required in original.
  • Contains: Name, age, gender of the patient
  • Name of the treating consultant
  • Date of admission and Discharge
  • Diagnosis and Condition of the patient on admission
  • Treatment given during hospitalization &
  • Operative notes (if any)
  • Laboratory Investigations carried out during hospitalization
  • Advice on discharge
  • Sign of the doctor and stamp of the hospital
  • Registration number of the hospital


What is the significance of Death Summary?

  • Always required in original
  • Legal document
  • Mandatory document
  • Contains in detail the course throughout the hospitalization, cause & time of death along with all the other details


What is MLC?

  • MLC is a Medico-legal Certificate and Xerox copy is required while submitting a claim
  • Asked only in RTA/assault cases.
  • It contains all the details of the accident/incidence i.e. how, when, where.
  • If MLC was not done, then the DR for MLC can be closed only if a letter stating the same is submitted on the hospital letterhead.


How important are Indoor Case Papers?

  • Attested Xerox required. Original copy never produced by the hospital
  • A set of ICPs consists of daily progress notes and the daily nursing chart.
  • Set of documents maintained by the hospital for every indoor patient.
  • It contains all the details of the patient right from time of admission up to the time of discharge i.e. each and every major and minor events during the course of hospitalization.
  • The notes and observations made by each and every doctor during their rounds/visits and their advise.
  • If any surgery/procedure is performed during the hospitalization, then detailed operative notes are mentioned along with the type of Anesthesia used, and the post operative condition of the patient.
  • Most importantly, it mentions in detail the treatment administered to the patient during hospitalization.
  • It is not a part of the checklist, but it is asked (depending on the claim).
  • It is mandatory for the case if asked as it is essential to decide acceptability of the claim for settlement.
  • Contents of nursing chart is the nurses record of Temperature, Pulse and B.P


What do I need to check during admission?

  • Room rent availability in hospital
  • Your room rent eligibility
  • In case of any surgery the tariff rate of the hospital
  • In case of surgery and hospital is in GIPSA panel all related details
  • Your balance sum insured
  • Expected length of stay in case of all planned admissions
  • While the hospital faxes preauthorization, if all investigations and treatment sheets are sent to TPA


What is room rent eligibility?
This is the maximum room you are eligible as per policy. In case the exact room is not available in the hospital you are admitted, please check for the next available lower room.

What is proportionate / percentage deduction as per room eligibility?
If the room opted is higher than eligibility, all charges that vary as per rooms in hospital are deducted proportionate to the same.

What is GIPSA?
GIPSA stands for General Insurers Public Sector Association. 4 public sector insurers have created an association and empanelled hospitals for fixed closed packages for specific surgeries in specific rooms.

Points to be checked:
GIPSA panel hospitals
GIPSA procedures
GIPSA packages
Your room eligibility Vs GIPSA agreed room

What is the meaning of exclusions of policy?
Few ailments and complications related to the same are not payable as per policy, please refer to your policy copy for more details.


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Do's during Admission

  • Check the network hospitals for your insurer
  • Check the hospitals under GIPSA panel (We have negotiated rates with these hospitals for certain procedures)
  • Check your room eligibility
  • Check the tariff rate for your room.
  • Avail the room which you are eligible for (else a percentage of all room related charges will have to be borne by you)
  • In case GIPSA room is within your eligibility prefer the same.
  • Get the preauthorization form completely filled.
  • Send all investigation reports with the preauthorization form to TPA
  • Before discharge check if hospital has sent final bill, discharge summary to TPA
  • Send claim intimation to TPA
  • Send all original documents to TPA for processing your claim


Don'ts during admission?

  • Do not avail a higher than eligible room


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