Your Insurance / TPA empanelment with SGRH
To ensure a smooth admission process, it's important to check if your Insurance Company/TPA is associated with Sir Ganga Ram Hospital or if the hospital is covered under their list of network hospitals for Cashless Treatment. You can contact your agent or the insurance/TPA provider to confirm this. If the hospital is not empanelled, you may have to pay for the treatment out of your pocket and then claim reimbursement from the insurance/TPA. To avoid any inconvenience, we recommend checking the list of network hospitals covered under your policy and finding a suitable hospital accordingly.
Type of Policy
To make sure you understand your healthcare coverage, it's important to know whether you have an individual policy or a group policy provided by your employer. There are a few differences between the two that you should be aware of, and you can get more information by speaking with your insurance agent, insurance company, or TPA service provider.
Coverage: An individual policy offers coverage to an individual and their family, while a group policy offers coverage to all employees of the organization and their family members. Group policies may have a lower sum insured and fewer benefits compared to individual policies.
Premium: In an individual policy, the premium is paid by the policyholder, while in a group policy, the premium is paid by the employer.
Waiting period: The waiting period for pre-existing diseases may vary between individual and group policies. Group policies may have a shorter waiting period or no waiting period at all.
Portability: An individual policy can be ported from one insurer to another, while a group policy cannot be ported if the employee leaves the organization.
Customization: An individual policy can be customized as per the policyholder's requirements, while a group policy cannot be customized as it is a standardized policy provided by the employer. vi. Renewal: In an individual policy, the policyholder is responsible for renewing the policy, while in a group policy, the employer renews the policy for all employees.
Coverage Details
The beneficiary should check the following details in the coverage details of the policy.
Sum insured: The sum insured is the maximum amount that the insurance company will pay for the treatment. The beneficiary should ensure that the sum insured is adequate to cover the cost of the treatment they require.
Deductibles: A deductible is an amount that the beneficiary needs to pay from their pocket before the insurance company starts paying for the treatment. The beneficiary should check the deductible amount and ensure that they can afford to pay it.
Co-payment: Co-payment is the percentage of the treatment cost that the beneficiary needs to pay from their pocket, and the insurance company pays the remaining amount. The beneficiary should check the co-payment percentage and ensure that they can afford to pay it.
Room rent: The insurance policy may have a limit on the room rent, and the beneficiary should check whether the room they plan to get admitted to is covered under the policy.
Sub-limits: The policy may have sub-limits for certain treatments, such as surgeries, diagnostic tests, and consultations. The beneficiary should check the sub-limits and ensure that they are adequate to cover the cost of the treatment.
Waiting period: Some policies have a waiting period before certain treatments or illnesses are covered. The beneficiary should check whether any waiting period applies to their policy.
Exclusions: The beneficiary should be aware of the exclusions under their policy to avoid any unexpected costs.
Exclusions
The beneficiary should be aware of the exclusions under their policy to avoid any unexpected costs. Common exclusions of an insurance policy are the specific situations, treatments, or services that are not covered under the policy. Here are some common exclusions that are typically found in insurance policies:
Pre-existing conditions: Most insurance policies do not cover pre-existing conditions or illnesses that existed before the policy was purchased.
Cosmetic procedures: Cosmetic procedures such as plastic surgery, hair transplant, or any other non-medically necessary procedures are usually excluded from the coverage. iii. Alternative treatments: Alternative treatments such as acupuncture, homeopathy, or herbal medicines are often excluded from coverage.
Dental treatments: Dental treatments such as dental implants, braces, or cosmetic dental procedures are usually excluded from the coverage.
Pregnancy and childbirth: Most insurance policies do not cover pregnancy and childbirth-related expenses unless specifically mentioned in the policy. ( Check with an agent )
Injuries resulting from risky activities: Injuries resulting from risky activities such as adventure sports, bungee jumping, or skydiving are usually excluded from the coverage.
Self-inflicted injuries: Injuries resulting from self-harm or suicide attempts are usually excluded from the coverage. viii. Injuries and diseases related to Alcohol and substance abuse ( drugs).
Sexually Transmitted diseases: HIV /AIDS.
Mental Illnesses
Additional Exclusions
In addition to the above common exclusions, there may be some exclusions in the fine print of the policy that the beneficiary may not be aware of. These exclusions may include:
Specific illnesses or treatments not covered: Some policies may exclude coverage for certain illnesses or treatments that are not mentioned in the policy brochure or summary.
Exclusions related to age or medical history: Some policies may exclude coverage for individuals above a certain age or those with a specific medical history.
Exclusions related to pre-authorization: Some policies may exclude coverage for treatments that are not pre-authorized by the insurance company or TPA.
Exclusions related to the provider network: Some policies may only cover treatments received from specific hospitals or providers and exclude coverage for treatments received outside the network.
It is important for the beneficiary to read the policy documents carefully and understand the exclusions to avoid any unexpected expenses. If the beneficiary has any doubts or questions about the coverage, they should clarify them with the insurance company or TPA before seeking treatment.
Waiting Period
Some policies have a waiting period before certain treatments or illnesses are covered. The beneficiary should check whether any waiting period applies to their policy.
The waiting period in an insurance policy refers to the period during which the insured person is not eligible to make a claim for certain specific illnesses or treatments. The waiting period is typically mentioned in the insurance policy documents and varies depending on the type of policy and the insurance company.
The waiting period is designed to protect insurance companies from fraudulent claims and to ensure that people do not purchase policies only when they require immediate medical attention. Waiting periods can range from 30 days to 4 years depending on the policy and the type of treatment.
For example, a health insurance policy may have a waiting period of 30 days for any illness or injury, which means that the insured person cannot make a claim for any medical expenses incurred during the first 30 days of the policy.
Similarly, a policy may have a waiting period of 2 years for pre-existing conditions, which means that the insured person cannot make a claim for any medical expenses related to pre-existing conditions until the waiting period is over.
It is important for the beneficiary to be aware of the waiting period and plan accordingly. The waiting period starts from the date of the policy purchase or renewal and cannot be waived off.
If the beneficiary requires medical attention during the waiting period, they would have to bear the expenses out of their own pocket. Therefore, it is recommended that the beneficiary purchases an insurance policy well in advance and ensures that the waiting period has expired before seeking any medical treatment.
Renewal Details
The beneficiary should check the renewal details of their policy, including the renewal date and the process for renewing the policy.
Checking the renewal details of an insurance policy is important to ensure that the policy remains valid and active. If the policy is not renewed on time, the beneficiary may not be able to make any claims or may have to face a waiting period again.
Here are some important things that the beneficiary should check in the renewal details of their insurance policy:
Renewal date: The beneficiary should check the renewal date of their policy to ensure that it is renewed on time. If the policy is not renewed before the expiry date, the beneficiary may lose their coverage and have to start again with a new policy.
Premium amount: The beneficiary should check the premium amount to ensure that it has not increased significantly. If the premium amount has increased, the beneficiary should check with the insurance company to understand the reasons for the increase and whether it is reasonable.
Changes in coverage: The beneficiary should check whether there have been any changes in the coverage offered by the policy. If there are any changes, the beneficiary should check whether they are acceptable or whether they need to look for a new policy.
Exclusions and waiting periods: The beneficiary should check whether there have been any changes in the exclusions or waiting periods mentioned in the policy. If there are any changes, the beneficiary should check whether they are acceptable or whether they need to look for a new policy.
No-claim bonus: If the policy offers a no-claim bonus, the beneficiary should check whether they have accumulated any bonus and whether it has been carried forward to the new policy term.
It is important for the beneficiary to review the renewal details of their policy carefully and make sure that they understand the changes, if any. If the beneficiary has any doubts or questions, they should clarify them with the insurance company or TPA before renewing the policy.
By checking these details, the beneficiary can ensure that their insurance policy will cover the treatment they require and avoid any surprises or unexpected expenses.
