1.The Members will be identified by the Service Provider on the basis of an ID card issued to them bearing the logo and the wordings of insurance. The ID card shall have photograph or signature or thumb impression of the Insured. In some cases the member may have only the Authority letter/Pre-certification issued by insurance along with the employee ID of the corporate.
2.For the ease of Members, the Service Provider shall display the recognition and promotional material, network status and procedures for admission supplied by insurance at prominent locations, preferably at the reception and admission counter and Casualty/Emergency departments. The Service Provider shall ensure that its staff obtains Pre-Authorization.
A. Planned Admission
i. Request for admission on behalf of the Member may be made by the Service Provider or consultant attached to the Service Provider as per the prescribed format. The Pre- Authorization form needs to give the details of the Member’s proposed admission along with the necessary medical details and the treatment planned to be administered and the breakup of the estimated cost.
ii. The request for authorization should be received prior to admission.
B. Emergency admission
i. The Parties agree that the Service Provider shall admit the Member(s) upon the production of the ID card issued by insurance as per the Service Provider rules & regulations, when the Member is carrying a valid ID card issued by insurance
ii. In case of vehicular accident, if the injured/sufferer was under the influence of alcohol or inebriating drugs, if detected or suspected, since the insurance benefit is not available for such cases, the Service Provider shall treat the admission as per its normal practice and not under cashless or being entitled to indemnity from insurer.
iii. In case of other emergencies, Service Provider upon deciding to admit the Member should inform/ intimate over phone immediately to the insurance helpdesk.
iv. insurance agrees and undertakes to have their medical team to get in touch within 6 working hours on best effort basis of the Service Provider after the telephonic intimation and issue the authorization for admission under cashless if admissible. It is clarified that the insurance shall not be liable for any delay or failure in providing the confirmation and insurance shall not be liable for any amounts until it has issued a confirmation.
v. In case of emergency admission, within a period of 24 hours from the time of admission a Pre-Authorization form should be forwarded which would give the details like present illness/past history, diagnosis, and estimated cost of treatment along with first prescription collected from Member.
vi. On receipt of the Pre-Authorization form for the Member giving the details of the ailments for admission and the estimated treatment cost, which is to be forwarded within 24 hours of admission, insurance undertakes to issue the confirmation letter for the admissible amount or rejection letter within 12 hours of the receipt of the Pre- Authorization form subject to policy terms & conditions. It is clarified that the insurance shall not be liable for any delay or failure in providing the confirmation and insurance shall not be liable for any amounts until it has issued a confirmation.
3.In case the ailment is not covered or given medical data is not sufficient for the medical team to confirm the eligibility, insurance can deny the authorization/issue partial authorization which shall be addressed to the Member under intimation to the Service Provider. The Service Provider will have to follow its normal practice in such cases and will not have any recourse to Religare Health. The power to deny the claim shall vest only with Religare Health.
4.Denial of Authorization/ guarantee of payment in no way mean denial of treatment. The Service Provider shall deal with each case as per their normal rules and regulations. However, insurance shall not be in any manner liable to the Service Provider for any expenses incurred in respect of cases where authorization is denied.
5.Authorization certificate will mention the amount approved class of admission, eligibility of Insured or various sub limits for rooms and board, surgical fees etc. wherever applicable, as per the benefit plan of the Member. Service Provider must ensure compliance of the same.
6.The authorization is given only for the necessary treatment cost of the ailment covered and mentioned in the request for hospitalization. Non-covered items like Telephone usage, TV, relatives’ food, provider registration fees, documentation fees etc which insurance will update the Service Provider from time to time depending on the product exclusions, must be collected directly from the Member. Any investigation carried out at the request of the Member but not forming the necessary part of the treatment also must be collected from the Member.
7.In case the sum available is considerably less than the estimated treatment cost, Service Provider should follow their norms of deposit/ running bills etc., to ensure that they realize any excess sum payable by the Members not provided for by indemnity insurance shall not have any liability or obligation for any such dues to the Service Provider in case of non-recovery from the Member.
8.As per AML Guidelines the KYC documents i.e. identity proof and address proof of the patient (Member) on whose behalf payment would be made to the hospital needs to be collected. Service Provider shall collect the same from the patient (Member) and submit it to insurance along with the Request of Authorization.