Insurance

Medical insurance is crucial for managing your health and well-being, providing peace of mind and financial security. It is particularly beneficial in unforeseen medical emergencies or accidents, relieving the financial burden on both you and your family.

This section offers valuable information about your coverage, including insurance policies, deductibles, and co-pays, to help you navigate the insurance process, making it easier to receive cashless treatment and make the most of your medical insurance coverage.

To ensure that your insurance covers your treatment with us, we recommend that you check with your insurance agent to confirm whether SGRH is on their impanelled list. The names of all impanelled Insurance/TPAs is displayed at our Insurance Helpdesk.

Our friendly and knowledgeable staff are available to answer any questions and provide personalized support to help you make informed decisions about your healthcare.

Insurance /TPA Help Desk

Please contact the Helpdesk within 12 hours of admission.

To ensure that your admission process is as smooth and stress-free as possible, we recommend that you keep the following information and documents handy before seeking assistance from our Helpdesk:

Pre-authorization Process

Pre-authorization is a process that involves seeking approval from your insurance company or third-party administrator (TPA) before receiving certain medical treatments or procedures. This step is taken to ensure that the treatment you are seeking is necessary and covered under your insurance policy. When pre-authorization is obtained, the hospital can start the required treatment based on the estimated cost. However, it is important to note that final approval is also required to be taken at the time of discharge for the exact cost of treatment.

Find out more...

 

When applying for preauthorization, the following documents are commonly required:    

Valid Identification prooof (KYC): A government-issued ID card, such as a passport, driver's license, or national identification card. The identification document is used to verify the identity of the patient and ensure that the preauthorization request aligns with the policyholder's information.

Preauthorization Request Form: This form is typically provided by the insurance company or the hospital. It includes details such as patient information, policy number, treating doctor's information, and the nature of the medical procedure or treatment being sought.

Health Insurance Card/Policy Details:  You will need to provide a copy of your health insurance card or policy documents, which contain information about your coverage, policy number, and the name of the insurance company.

Doctor's Prescription: A prescription from your treating doctor recommending the specific treatment or procedure is typically required. It should include details such as the diagnosis, the recommended course of treatment, and the expected duration.

Medical Reports and Diagnosis: Documents related to your medical condition, such as medical reports, diagnostic test results, and any specialist consultation reports, should be included. These reports help the insurance company assess the necessity and appropriateness of the treatment or procedure.

Cost Estimate: A detailed cost estimate from the hospital or healthcare provider outlining the anticipated charges for the proposed treatment or procedure is usually necessary. This helps the insurance company determine the coverage amount and any applicable deductibles or co-payments.

Any Additional Supporting Documents: Depending on the nature of the treatment or procedure, additional documents may be required. These can include prior authorization letters, medical history records, imaging scans, or any other relevant medical documentation.   

All these are explained in detail below:

Your Id (KYC) Proof

Aadhar No./Card of both the patient and policyholder,  PAN Card of the patient and policyholder. Passport size photographs of the patient and policyholder both.

Name and other personal details – It is mandatory that the Full Name ( with exact spelling ) and Date of Birth are identical in the KYC documents submitted, Medical documents including prescription, and those provided at the time of Registration with the Hospital. Any discrepancy will result in the denial of approval by the Insurance /TPA and payment for the treatment has to be borne out of pocket by the patient.

KYC documentation for verification may vary depending on the specific insurance company or TPA involved, but in general, the following documents are typically required:

Find out more about KYC Documentation

Your Insurance Policy Details

Insurance policy documents include (not limited to):

•    Insurance Policy number.
•    Validity of Insurance for Current year.
•    Sum assured /remaining sum assured of the policy period.
•    Coverage details, and contact information for the insurance company or TPA.
•    Room Rent, Disease capping if any.
•    Co-Payment details (if any) - the cost of treatment that is to be paid directly by the policyholder.
•    Exclusions, payment of Non - medical expenses (check details).

It is always recommended for a beneficiary to check the details of their insurance policy before being admitted to a hospital. This can help make informed decisions about\ healthcare expenses and ensure that the terms and conditions of their policy are understood.

Check the following for your Insurance Policy

Your Doctor's Referral or Prescription

To make the process of admission for cashless treatment at Sir Ganga Ram Hospital as smooth as possible, it is essential for patients to obtain a prescription from a SGRH consultant which clearly states their requirement for admission. The prescription should include the following details:

Name and address of the patient - The patient's full name and current address should be clearly mentioned on the prescription.

Date of the prescription -  The date on which the prescription was issued should be clearly mentioned.

Name of the consultant -  The name of the SGRH consultant who has prescribed admission to Sir Ganga Ram Hospital should be clearly mentioned.

Reason for admission - The reason for the patient's admission should be clearly mentioned on the prescription.

Duration of admission - The duration for which the patient is being admitted to the hospital should be clearly mentioned.

Relevant Medical Records or Test Reports

Insurance company to ensure that the treatment being provided is necessary and within the scope of the policy coverage. These reports help the insurance company determine the extent of the treatment required and the associated costs, which are then compared against the policy limits and conditions to approve the cashless treatment.

By doing so, the insurance company ensures that the treatment is medically necessary and not fraudulent or unnecessary, thereby protecting both the policyholder and the insurance company's interests.

Find out more...

Cost Estimate

A detailed cost estimate from the hospital or healthcare provider helps the insurance company assess the anticipated charges for the proposed treatment or procedure. It allows them to determine the coverage amount based on the policy terms and conditions, as well as any applicable deductibles or co-payments that the patient may be responsible for. The cost estimate provides transparency regarding the financial aspects of the medical care, enabling the insurance company and the patient to make informed decisions regarding coverage and out-of-pocket expenses.

General Grounds of Denial in Health Insurance Policy

(not limited to)  alcohol consumption, hormone deficiency, opd treatment, normal baby charges, pre-existing illness within 4 years waiting, tests only  (except cardio angiography), sleep disorders, stds sexually transmitted diseases, chemoport insertion / removal, duration of illness vis-à-vis taking the policy, bronchoscopy (diagnostic / therapeutic), endoscopy (upper gi / lower gi) (diagnostic / therapeutic), waiting period of two years (on fresh or broken insurance), genetic conditions, infertility, ivf, ivlg therapy, oral chemotherapy, maternity related complications, robotic surgery charges, substance abuse, suicide attempt, cosmetic surgery, dental treatment (except due to accident), bariatric surgery, false documentation.

Final Approval

The process of final approval from insurance at the time of discharge may vary depending on the specific insurance company or TPA (Third Party Administrator) involved, but generally, the following steps are involved:

· The hospital will submit the final bill to the insurance company/TPA for final approval. Please obtain final bill from the Billing department in Room No. 17

· The insurance company/TPA will review the bill and ensure that it meets the terms and conditions of the policy.

· If there are any discrepancies or missing information, the insurance company/TPA may request additional documentation or clarification from the hospital.

· Once the bill is approved, the insurance company/TPA will issue a final approval.

· The Final Approval will specify the amount that the insurance company/TPA will pay towards the final bill, and any remaining balance will need to be paid by the patient.

· The hospital will provide the patient with a discharge summary and any other relevant documents.

· The patient will need to sign the discharge summary and make any necessary payments.

· Once the payment is made, the patient can be discharged from the hospital.

It is important to note that the final approval process may take 3-4 hours’ time after the documents required by the Insurance TPA have been submitted, it is recommended to check with your insurance company/TPA and the beforehand to understand the approval process and avoid any unexpected expenses.

Final Billing

Hospital is not liable for any Cashless/Reimbursement claim rejection by Insurance company TPA.