Frequently asked questions
Tell me about hospitalization
Hospitalization can be of two types:
- Planned Hospitalization: This happens when you have ample time to plan your admission to the hospital. For example, if your doctor advises a surgery for hernia anytime in the next few weeks, you have time to plan your hospitalization.
- Emergency Hospitalization: This happens typically in case of emergencies, such as a road traffic accident. One cannot plan for such hospitalization.
What are the types of hospitalization expenses typically covered by my policy?
Apart from hospitalization expenses, your health insurance policy may cover several other expenses (subject to terms and caps). Expenses associated with hospitalization can typically be classified as follows:
- Pre-hospitalization expenses: When you're unwell, you will most likely consult a physician first, who gets relevant investigations done before advising hospitalization. Such medical expenses incurred before hospitalization are called pre-hospitalization expenses.
- Hospitalization expenses: All expenses incurred as part of your hospital stay as an in-patient can be termed as hospitalization expenses.
- Post-hospitalization expenses: Some part of your treatment may extend beyond your hospitalization. It may involve follow-up visits to the doctor, prescription medication, further investigations, etc. Such medical expenses are called post-hospitalization expenses.
- Domiciliary hospitalization expenses: This typically includes expenses related to domiciliary hospitalization - at-home medical treatment (for reasons such as inability to move the patient) for more than three days for cases which in the normal course would require hospitalization. The exact circumstances / terms / exclusions related to domiciliary hospitalization would be spelt out in your policy document.
Are my medical expenses incurred before and after hospitalization covered?
Your policy may allow reimbursement of relevant medical expenses incurred during, pre- & post-hospitalization for the particular condition for which hospitalization was necessary. This is subject to the terms and limits prescribed in the policy. Please read your policy document in detail.
What are Non Admissible Expenses?
What is co-pay?
Co-pay is a percentage applied on payable amount which the policyholder has to pay at the time of discharge. The rest of the amount is paid by the insurance company.
What are the different types of claims?
Depending on the situation and your policy coverage, you can make two types of health insurance claims:
- Cashless: The essence of cashless hospitalization is that the insured need not make an upfront payment to the hospital at the time of admission. You may not have any out-of-pocket expenses towards hospitalization in this scenario. Cashless hospitalization can be availed only at a Medi Assist network hospital and upon approval of your pre-authorization application.
- Reimbursement: A reimbursement claim is one where you pay all the expenses related to the hospitalization of the insured and claim a reimbursement of your expenses after discharge. Reimbursement claims may be filed in the following circumstances:
- Hospitalization at a non-network hospital
- Post-hospitalization and pre-hospitalization expenses
- Denial of pre-authorization for cashless facility at a network hospital.
What is planned hospitalization?
If you are aware of the fact that you or your family members require hospitalization in the near future, you can send prior intimation to Medi Assist to plan your hospitalization. Not only does this ease the admission and pre-authorization process, but it also helps reduce your overall cost of treatment wherever possible.
Once Medi Assist receives the intimation, we will help you plan everything including choosing a network hospital, opting for discounted packages, if available, and planning for cashless hospitalization.
What is the process for cashless hospitalization?
Cashless hospitalization can be availed only at Medi Assist network of hospitals. Here is the generic process to avail cashless hospitalization:
- Intimate Medi Assist about your hospitalization.
- Present your Medi Assist e-card at the hospital during admission along with any other legally accepted identity card.
Note: You can log into your Medi Assist online portal and click Generate E-Card to instantly generate and print out an e-card for any beneficiary. - Ensure that the hospital sends your pre-authorization form to Medi Assist.
- Track your claim in real-time using Medi Assist Portal or MAven app.
- Medi Assist sends the approval to the hospital. Further enhancement approvals may be issued on request, subject to terms and conditions of the policy.
- In case the request cannot be approved or if the expenses are not covered by your policy, you will have to settle the hospital bill in full and subsequently raise a reimbursement claim after discharge
Note: Denial of a preauthorization request must not be construed as denial of treatment or denial of coverage. - After discharge, the hospital will send all the documents related to your claim to Medi Assist for settlement.
Is there any time limit to submit the pre-authorization request?
In case of an emergency or unplanned admission, the hospital must send the pre-authorization request to Medi Assist within 24 hours from the time of admission. In case of a planned hospitalization, it is prudent to send the preauthorization request to Medi Assist at least 72 hours prior to the admission date. This will ensure a hassle-free admission procedure for you at the hospital.
How do I raise a reimbursement claim?
Although cashless hospitalization facility is available at the Medi Assist network of hospitals, you may sometimes need to use hospitals that are not in the Medi Assist network. Reimbursement claims may be filed in the following circumstances:
- Hospitalization at a non-network hospital
- Post- and pre-hospitalization expenses / domiciliary expenses that are not covered by your policy
- Denial of preauthorization for specific reasons.
In such cases, you can claim a reimbursement after discharge.
- Intimate us about your impending claim.
- Present your Medi Assist e-card at the hospital during admission along with any other legally accepted identity card.
Note: You can log into your Medi Assist online portal and click Generate E-Card to instantly generate and print out an e-card for any beneficiary. - Submit your reimbursement claim online within 7 days from date of discharge.
- Send the original documents to Medi Assist within 30 days from the date of discharge from hospital.
- Track your claim in real-time.
- The medical team at Medi Assist processes the claim:
- In case of approval, the amount is reimbursed either via NEFT or cheque (sent to the address mentioned in your policy).
- In case your claim is denied, the denial letter is sent to you by courier / post / e-mail quoting the reason for denial of your claim.
What documents must I submit for a reimbursement claim?
The following are the documents that you would have to submit while claiming a reimbursement:
- Original hospital final bill
- Original numbered receipts for payments made to the hospital
- Complete breakup of the hospital bill
- Original discharge summary
- All original investigation reports along with prescriptions
- All original medicine bills with relevant prescriptions
- Original signed claim form
- Copy of the Medi Assist ID card or current policy copy and previous years’ policy copies (if any)
- Covering letter stating your complete address, contact numbers and email address (if available).
What is the deadline to submit a reimbursement claim?
Claim intimation (with particulars relating to policy number, name of the insured person for whom the claim is made, nature of illness/injury and name and address of the attending medical practitioner/hospital/nursing home) should be submitted within 7 (seven) days from the date of hospitalisation/injury.
How long does it take to process the reimbursement claim and when will I receive the payment after approval of the claim?
After receiving all the required documents, it takes 15 working days to process the claim and 7 working days after that for payment.
What is the maximum number of claims allowed during the policy period?
There is no upper limit on the number of claims that can be raised during the policy period. However, the total cumulative claim amount cannot exceed the sum insured in the policy.
The final claim form along with the hospital receipt, bills, cash memos and the list of documents as listed in the claim form should be submitted to Medi Assist within 30 (thirty) days from the date of discharge from the hospital.
What happens to my sum insured after a claim is filed? And what happens if the cost exceeds my hospital insurance cover?
The sum insured is reduced by the amount of the claim paid for the rest of the policy year. You have to pay the balance amount if your claim exceeds the sum insured.
What are shortfall documents or information required (IR), and when and where do I send them?
Shortfall documents are raised if the documents already sent are insufficient for further validation of the existing claim. They have to be sent within 10 working days of the receipt of the e-mail notifying you of insufficient documentation.
If you are an individual policyholder, you can submit the shortfall documents to the nearest Medi Assist branch. If you are a corporate employee, just hand them over to the respective helpdesk person.
