GIPSA, a group of 4 PSU general insurance companies, decided to

standardise rates for around 42 medical procedures across

various categories of over 4000 hospitals for settling cashless
claims but is looting and cheating patient by GOOF-up with
hospital and TPA. GIPSA in package is almost 4 times the rate that
any patient can do a procedure under cash payment in same
hospital or ends up paying 3 times than when patient is insured
with pvt. insurer company. Thus it seems that GIPSA is to
promote PVt. company business which was earleir negligible but
now has already reach to 50% market share after GIPSA came
into effect on July 2010. There is no GIPSA website. GIPSA
common monopoly rates for 4 PSU is against the original policy
because of which it was necessary to create 4 PSU for competition.
Claim Guide

In simple terms, insurance is a method of sharing the unexpected financial

losses of an ‘unfortunate few’ from a common fund formed out of contributions
of the ‘many’, who are equally exposed to the same loss (Spreading of the losses
of an individual over a group of individuals). Health Insurance pays for
unexpected Hospitalisation expenses of those few insured persons who suffer
from illness or injury requiring treatment as inpatient in a Hospital/Nursing
Home, out of contributions (Premium) of many insured persons who are exposed
to similar health risks. Refer Cashless Claim Guide to understand the process. ut
of contributions of the ‘many’, who are equally exposed to the same loss
(Spreading of the losses of an individual over a group of individuals). Health
Insurance pays for unexpected Hospitalisation expenses of those few insured
persons who suffer from illness or injury requiring treatment as inpatient in a
Hospital/Nursing Home, out of contributions (Premium) of many insured persons
who are exposed to similar health risks. Refer Cashless Claim Guide to
understand the process.

Understanding Insurance

In simple terms, insurance is a method of sharing the unexpected financial

losses of an ‘unfortunate few’ from a common fund formed out of contributions
of the ‘many’, who are equally exposed to the same loss (Spreading of the losses
of an individual over a group of individuals). Health Insurance pays for
unexpected Hospitalisation expenses of those few insured persons who suffer
from illness or injury requiring treatment as inpatient in a Hospital/Nursing
Home, out of contributions (Premium) of many insured persons who are exposed
to similar health risks. Refer Cashless Claim Guide to understand the process.

Scope of Cover
The policy is meant to cover only the unexpected Hospitalisation Expenses and
not any OR all medical expenses incurred.

The objective of the Policy is to cover Hospitalisation expenses for treatment of

the ailment/injury requiring in-patient care wherein effective treatment would
not have been possible on out-patient basis. If the admission of the patient is
primarily for diagnostics and investigation and / or observation and evaluation,
the Hospitalisation expenses are not reimbursed.

The policy is liable only to meet the expenses that are necessarily and
reasonably incurred for treatment of the ailment.

There are certain expenses that are not admissible under the Health Insurance
Policies, even though they would be necessary medical expenses. Please check
the List of Non-admissible Expenses.
 The Policy covers hospitalisation anywhere in India.

The minimum requirements for admissibility of the claim under your Health
Insurance Policy are:
 The person should have been covered under the Health Insurance Policy
 The hospitalisation should occur when the policy is valid / in force.
 Treatment for the ailment/injury cannot be done as an Out-Patient and
requires admission as inpatient for a minimum period of 24 hours. Relaxation of
minimum period of 24 hours is allowed for certain procedures or treatments
like Cataract, Dialysis, Chemotherapy, etc. Please read your policy for the exact
list of these procedures / treatments.
 Hospitalisation should be for curative purpose with active line of treatment
and not for observation, evaluation or diagnostic purpose.
 Hospital should have been registered with the local authorities or it should
meet the definition of a Hospital as described in the Policy with respect to
number of beds, availability of Medical doctor & nursing staff round the clock,
Operation Theatre, etc.
 The ailment or injury for which treatment is given does not fall under
excluded diseases/conditions such as self inflicted injury, related to alcohol,
congenital external conditions etc more specifically described in the Policy.
Please refer to your policy for the list of exclusions.
 The line of Treatment should be proven and accepted and not
experimental or unproven.
The above minimum requirements for admissibility of a claim are only indicative
and not exhaustive.

Systems of Medicine
Health insurance in India generally covers Allopathy, Ayurveda, Homeopathy and
Unani systems of medicine. But specific policies may have special terms and
conditions according to which claims would be admissible only for Allopathic
system of medicine and alternative systems of medicine may not become
payable . Health Insurance Policies do not cover treatments which are not
approved or which are experimental in nature. Some of these are: Acupuncture/
Acupressure/ Ozone Therapy/ Music Therapy/ Magneto Therapy/ Electro
Magneto Therapy/ RFQMR/ Hypnotherapy/ Naturopathy/ Aroma Therapy/ Baleno
Therapy etc.

Admissible Expenses
The expenses such as Room/ Bed Charges, Nursing Charges; Professional
charges such as Consultant, Surgeon, Anesthetist etc; and expenses for
investigations, diagnostics and Laboratory; Cost of implants like Stents,
Intraocular lens, Pacemaker; Medicines, Drugs, Operation Theatre Charges, etc.
are payable under the Health Insurance Policy.

Any other expenses not falling under any of the above headings are not payable
like Telephone Charges, Service or Surcharges, Administrative charges, etc.
Some of the policies list out the non-admissible expenses. You may visit our
website for a comprehensive list of Non-admissible Expenses.
 Limitation to the Admissible Expenses
The main limit in Health Insurance is the Sum Insured. Any medical expenses
incurred over and above the Sum Insured will not be payable. However, if the
policy is subject to ‘Cumulative Bonus’ the total policy limit shall be the Sum
Insured + the Cumulative Bonus sum.

In addition to this, there may be various types of sub-limits depending on the

type of policy:
 Sub-limits within a family floater for certain categories of beneficiaries. Ex.
A Sum Insured sublimit of Rs. 100,000 for the parents within the family floater
of Rs. 500,000. This means that parents can use only Rs. 100,000 although the
overall family limit is defined as Rs. 500,000.
 Sub-limits for ailments/ procedures. Ex: Sub-limit of Rs. 50,000 for
maternity claims; sublimit of Rs. 150,000 for cardiac ailment claims, sublimit of
Rs. 32,000 for Appendicectomy, etc. All hospitalisation expenses admissible
in respect of the condition/ ailment will be restricted to the specified limit
during the policy period.
 Limit on the total liability of the Insurance in the event of a claim. Ex:
The policy condition may say that the Insurance Company will be liable to pay
only up to 80% of the Sum Insured. If Sum Insured is Rs. 100,000, the
insurance company will pay claims only up to Rs. 80,000.
 Some of the Policies may have a cap on the Room Rent/ ICU Limit per day
or prescribe a category of Room.
 Some of the policies may cap the other expenses like professional fee
and other charges admissible to the eligible room category
 Some Policies may prescribe maximum amount allowable under
Room/Profession Charges and other expenses at 25%, 25% & 50% of the Sum
Insured respectively
 Some policies may have a Co-pay to be borne by the Insured like 10%
Co-pay for all members of the family but 20% Co-pay for parents applicable on
the admissible amount.
 Non-allopathic treatments may have a cap on the admissible amount. For
Example, under New India policy for non-allopathic treatments like Ayurveda/
Homeopathy & Unani the limit is only 25% of the Sum Insured.

Pre & Post-Hospitalisation Expenses

When one falls sick, one usually consults a family physician and gets relevant
investigations done for proper diagnosis. The physician may initially prescribe
certain medications/ administer some injections too. In spite of this treatment,
the condition of the patient does not improve the physician advices the patient
to get hospitalized for further management of the disease. Such medical
expenses incurred before hospitalization are called Pre-Hospitalization Expenses.

During hospitalization, a major part of the treatment is complete but some part
of the treatment extends beyond the hospitalization. It may involve follow-up
visits to the doctor, medicines to be taken or follow-up investigations to be done.
Such medical expenses are called Post-Hospitalization Expenses.

Pre-hospitalisation Expenses up to 30 days and Post-hospitalisation Expenses up

to 30 or 60 days are generally payable under the Health Insurance Policy.
However, there are some insurance policies wherein this period may be of a
different duration.

Only those expenses relevant to the ailment for which the person has been
hospitalized shall be considered under Pre & Post-hospitalisation Expenses head.
Routine medications that the person would have been taking for the chronic
ailment the patient had will be out of scope of this head.

Sum Insured
If Health Insurance Policy is issued with a fixed sum insured against each
individual insured person, the Policy is on ‘Individual Sum Insured’ Basis. Any
claim beyond the Sum Insured set against the insured person is not payable for
that person. However, if the policy is subject to ‘Cumulative Bonus’ the total
policy limit shall be the Sum Insured + the Cumulative Bonus sum.

On the other hand if the Policy is issued with a consolidated Sum Insured for the
entire family with no individual Sum Insured break-up for each member of the
family, then policy is termed ‘Floater Sum Insured’ Policy. The Sum Insured
floats over the members of the family and one claim or multiple claims by one
member or more than one member of the family will be admissible up to the
Floater Sum Insured limit during the policy period unless per claim sub-limit,
beneficiary level sub-limit or ailment sub-limit is prescribed by the Health
Insurance Policy.

Day-care Procedures
Treatment or Surgical Procedures that can be conducted only in a hospital/
Nursing Home, where due to technological advancement the hospital stay is
required to be less than 24 hours, are considered Day Care procedures.
Cataract, Dialysis, and Lithotripsy are a few examples. The policies list out the
Day Care Procedures. Check your policy for the list of covered Day-care
Procedures.

Out-patient Treatment/ Domiciliary Treatment

The treatment for illnesses/ diseases/ injuries which do not require admission as
in-patient in the Hospital or nursing home and administered to the patient on
out-patient basis in a clinic or hospital or nursing home fall under Domiciliary
treatment. Most of the primary care treatments given in the clinic are considered
as Domiciliary Treatment. Domiciliary Treatment is also called Out-patient
Treatment. The expenses incurred for domiciliary treatment are not generally
covered under Mediclaim Policies unless it is specifically mentioned. Please check
your policy benefits for the coverage as well as the limits if any.
 Domiciliary Hospitalisation
Domiciliary Hospitalisation is not Domiciliary Treatment mentioned above. Some
of the policies admit a claim under Domiciliary hospitalisation when the medical
care and treatment for the disease/injury is taken at home but in the normal
course would require care and treatment in the Hospital or Nursing Home only
when

 The condition of the INSURED PERSON is such that he/she cannot be

removed to the HOSPITAL / NURSING HOME; or
 The INSURED PERSON cannot be removed to HOSPITAL / NURSING HOME
for the lack of accommodation therein;
 The period of treatment exceeding three days

It does not cover Pre and Post-hospitalisation expenses as well expenses for
treatment for listed diseases such as Asthma; Bronchitis; Chronic Nephritis and
Nephrotic Syndrome; Diarrhoea etc.

Cashless Hospitalisation
Health Insurance earlier entailed the complete settlement of the health care
services bill by the individual to the hospital, followed by a reimbursement claim
filed with the Insurance Company. The Insurance Regulatory Development
Authority in India initiated the Cashless Hospitalization Process through Third
Party Administration services for Health Insurance claims from 2002.

 Once you are covered under a Health Insurance Policy administered by us,
you will be issued a Vidal Health Insurance TPA Pvt Ltd ID card. If your health
insurance cover is issued through your employer, you may not be issued a
physical ID card but you may have an E-card. This card will facilitate you to avail
CASHLESS facility at the Networked Hospitals.
 Cashless hospitalization can be availed only at our network of hospitals.
The essence of cashless hospitalization is that the insured individual need not
make an upfront payment to the hospital at the time of admission
 Cashless is only a facility extended by the Third Party Administrators to
the Insured persons through their Network of Hospitals who have agreed to
certain terms and conditions.
 Cashless cannot be claimed as a matter of right and denial of a pre-
authorization request is in no way to be construed as denial of treatment or
denial of coverage or denial of your right to prefer reimbursement claim. You can
go ahead with the treatment, settle the hospital bills and submit the claim for a
possible reimbursement.
 If the policy covering you is subject to the GIPSA PPN arrangement,
please check for the nearest hospital that is in the GIPSA PPN Package
Agreement. Cashless facility for such policies will be available only in those
hospitals who are under the GIPSA PPN Arrangement.

Process for availing Cashless Hospitalisation Facility

 Plan admissions only in such hospitals that are in our Network. If your
policy is subject to GIPSA PPN Network, please get admitted only in such
hospital that is in the GIPSA PPN Network. Your admission elsewhere will lead to
denial of the cashless facility and even reimbursement of the expenses will be
subject to the limits as per the GIPSA PPN Tariff.
 Produce the ID card issued by us at the Hospital Help Desk – along with
any other ID Proof like DL/ Voter’s ID/ Passport etc in respect of THE PATIENT.
 Obtain the Pre-authorization Form from the Hospital Help Desk, complete
the Patient Information and resubmit to the Hospital Help Desk
 Please indicate our ID Card Number without fail. In case the policy is
taken by your employer you may also furnish the Employee Number.
 The Treating Doctor will complete the hospitalisation/ treatment
information and the hospital will fill up expected cost of treatment
 This form is submitted to us either online or by fax
 We will process the request and call for additional documents/
clarifications if the information furnished is inadequate.
 Once all the details are furnished, we will process the request as per the
terms and conditions as well as the exclusions therein and either approve or
reject the request based on the merits of the case.

Once the request is received, it is processed. Our medical team will determine
whether the condition requires admission and the treatment plan is covered by
your Health Insurance Policy. They will also check with all the other terms and
conditions of your Insurance Policy.

In case coverage is available, we will issue an approval to the hospital for a

specified amount depending on the disease, treatment, sum insured available
etc. This is sent by fax and e-mail (if available). The approval is called a “Pre-
authorisation”. This pre-authorisation entitles you to avail the treatment at the
hospital without paying for the medical expenses up to the authorised limit.

At the time of discharge, in case the amount authorized by us is not sufficient to

cover the hospitalization expenses, the hospital will make a second/ final request
on your behalf for sanction of additional amount. We will process this request
and sanction will be made subject to terms and conditions of your health
insurance policy.

Your policy may be subject to ‘Co-pay’. This is the compulsory amount that you
need to bear in respect of each and every hospitalisation claim. Please check for
this information. You are required to pay to the hospital the amount equal to the
co-pay and obtain the necessary Bill & receipt. The hospital has to submit the
proof for having collected this amount from you. If the hospital is not able to
produce the requisite proof in respect of collection of co-pay from you, twice the
amount of co-pay will be deducted as a penalty from the amount payable to the
hospital.

Please verify your policy benefits to check your eligibility for Room Charges etc.
An admission to a ward higher than your entitlement would cost your claim as
the amount payable will be reduced in proportion the eligible ward charges bear
to the higher ward charges billed.
 Once final sanction has been received by the hospital, please make sure that you
check and sign the original bills and Discharge Summary. Please carry home a
copy of the signed bill and the Discharge Summary and all your investigation
reports. This is for your reference and will also be useful during your future
healthcare needs.

The hospital will ask you to pay for all the Non-admissible Expenses in your bill.
You have to make this payment before discharge. You may check for the items
disallowed against the List of Non-admissible Expenses in the website.

In case, for whatever reason, the pre-authorisation request cannot be approved,

a letter denying preauthorization will be sent to the hospital. We may deny the
Pre-authorisation without assigning any reason. In this case, you will have to
settle the hospital bill in full by yourself.

Please note that denial of a Pre-authorization request is in no way to be

construed as denial of treatment or denial of coverage. You can go ahead with
the treatment, settle the hospital bills and submit the claim for a possible
reimbursement.

Reimbursement Claim Process

Reimbursement of the hospitalization expenses can be claimed where Cashless
Hospitalisation facility is not availed or treatment is availed in a Non-network
Hospital. You will have to settle the hospital bill, collect all original hospitalisation
documents and submit the documents to our office for their scrutinizing the
same in terms of the policy and check the admissibility or otherwise of the
claim/ expenses.

 Reimbursement claims may be filed in the following circumstances:

a. Hospitalization at a non-network hospital
b. Post-hospitalization and pre-hospitalisation expenses
c. Denial of preauthorisation on application for cashless facility at a
network hospital

 Reimbursement claims can be submitted to us through registered post /

courier or can be handed over at any of our Branches.

 One of the very basic requirements of insurance is ‘Claim Intimation’. It

simply means intimating us or the Insurance Company about the hospitalisation.
Some of the policies indicate a time frame of 24 hours or 7 days from the date of
admission, most of the policies require that intimation has to be lodged
immediately on admission. Non-compliance to this may make your claim
inadmissible.

 The documents that you need to submit for a hospitalization

reimbursement claim are:
a. Original hospital final bill
b. Pre-Numbered / Printed Receipts for payments made to the hospital
c. Complete break-up of the hospital bill
d. Original Detailed Discharge Summary
 e. All Investigation reports
f. All medicine bills with relevant prescriptions
g. Operation Theatre Notes in the event of a surgery performed
h. Sticker for the Implant, if any, used during surgery
i. A copy of the Invoice for the implant, if any, used during surgery
performed
j. Original duly completed and signed claim form
k. Duly completed and signed Medical Practitioner’s Form
l. Copy of our ID card or current policy copy and previous years’ policy
copies if any
m. Company Employee ID card if you and your family are insured through
your employer
n. Documents for National Electronic Fund Transfer (NEFT)
i. NEFT Format giving details of the Bank Account where you need
the claim amount to be transferred
ii. A copy of the page of the Bank Pass Book containing the Account
Number & the Name/ Address of the Account Holder
iii. A cancelled Cheque for the above Account in to which the claim
amount has to be transferred
o. Covering letter stating your complete current address, contact
numbers, email ID if available and the list of documents attached.

 The documents that you need to submit for a Post-hospitalization or a

Pre-hospitalization claim are:
a. Copy of the discharge summary of the corresponding hospitalization
b. All relevant doctors’ prescriptions for investigations and medication
c. All bills for investigations done with the respective reports
d. All bills for medicines supported by relevant prescriptions
e. NEFT Documents as above. (If you have furnished the NEFT Documents
for the main hospitalisation claim earlier, you may indicate that the amount be
transferred to the same Bank Account.)

 Once the reimbursement claim is received, it is processed. Our medical

team will determine whether the condition requiring admission and the
treatment are covered by your health insurance policy. They will also check with
all the other terms and conditions of your insurance policy. All Non-admissible
Expenses will be disallowed.

 The policies stipulate a period from the Date of Discharge within which the
claim documents have to be submitted. Submission of claim papers after the
stipulated period could lead to denial of the claim. Normally it is 7 days from the
date of discharge for hospitalisation claim and for Post-hospitalisation it is 7 days
from the date of completion of the post-hospitalisation treatment. Please check
for the time frame for submission of the claim papers. In case the claim papers
are submitted beyond 7 days from the date of discharge the claim is liable to be
denied as per the policy terms. Hence, ensure compliance to the time frame
without fail.

 Based on the processing of the claim, a denial or approval is executed. In

case of approval, settlement is made by transferring the approved amount to
your Bank Account. We will also send you the settlement particulars along with
the computation sheet to the address mentioned in your health insurance policy.
 In case you have been insured through your Company, the cheque will be
dispatched based on instructions received from your company.

 In case we require additional documents we may send you a Shortfall

Letter. Kindly comply with the requirements within the stipulated time. In case
you do not submit the required documents within the stipulated time, after 2
reminders we will reject the claim and send the Denial Letter. Once the claim is
denied as above, you will forfeit your right to the claim.

 In case your claim is denied, the denial letter is sent to you by courier /
post quoting the reason for denial of your claim. In case you have been insured
through your Company, the denial letter will be dispatched based on instructions
received from your company.

 In the event you are aggrieved with the settlement or the denial of the
claim, you may kindly represent your case to our Grievance Cell. You may also
refer the matter to your Insurer’s Grievance Cell.

 If you are not satisfied with the redressal of your grievance either through
our Grievance Cell or that of the Insurer, you may present your case before the
Insurance Ombudsman.

Network Providers
Network Hospitals
Any hospital that has entered into an agreement with us to provide Cashless
facility for our card-holders is called a Network Hospital. You can check at our
website or call our Call Centre to check whether a specific hospital is in the List
of our Network Hospitals. Please furnish the name of your Insurer &/or the name
of your Corporate in case you are covered by your employer to advise you
properly.

Apart from our general Network of Hospitals, there may be subsets of this
Network such as Preferred Provider Network, restricted network, insurer specific
network, etc. based on terms and conditions of different insurance policies /
products. The list of Network Hospitals is a dynamic list and therefore the latest
may be verified at our Website.

Restricted Network
In some policies, policy holder / insured is not allowed to avail cashless facility at
all our network hospitals. Within the general network, only specific hospitals are
available for the policy holder to avail cashless facility. This is called Restricted
Network. If the policy holder /insured wishes to avail treatment in any of the
other network hospitals, he cannot avail cashless facility, but instead, will have
to apply for reimbursement after settling the hospital bills himself / herself.

Preferred Provider Network

In some policies, where there is co-payment, there may be some hospitals
where this co-payment is not applicable. These are called Preferred Provider
Network hospitals. Such hospitals generally have a reasonable tariff rate
agreement with us for common procedures.

GIPSA Network
The Public Sector Insurers viz National Insurance Co Ltd., New India Assurance
Company Ltd, Oriental Insurance Co Ltd & United India Insurance Co Ltd have
negotiated special package rates for a good number of procedures commonly
undergone from many hospitals across India. Cashless facility for those
procedures is available only in the GIPSA Network Hospitals. Claim for treatment
taken elsewhere will have to be submitted for reimbursement.

Planned Hospitalisation
This happens when you have ample time to plan your admission to the hospital.
For example, if the doctor advises surgery for hernia and says that you can
undergo the surgery anytime in this month, it gives you time to plan your
surgery.
In such cases, it is prudent to send the preauthorization request to Vidal Health
Insurance TPA Pvt. Ltd. at least 72 hours before your planned admission.
This will ensure a hassle-free admission procedure for you at the hospital.

Emergency Hospitalisation
This happens typically in case of emergencies such as a road traffic accident or
in an acute condition like Acute Gastro Enteritis/ Acute Appendicitis etc. There is
no planning involved in the hospitalization. In such situations the Vidal Health
Insurance TPA Pvt. Ltd. ID card can be shown at the network hospital to avail
cashless admission facility. The preauthorization request can be sent to the Vidal
Health Insurance TPA Pvt. Ltd. within four hours after admission.

It is, therefore, prudent that every insured individual should carry their Vidal
Health Insurance TPA Pvt. Ltd. ID card with them at all times. You can never
predict an emergency!

Exclusions in a Health Insurance Policy

Health Insurance Policy is meant to cover unexpected, reasonable and
necessary/customary Medical expenses of Hospitalization either due to
an illness or injury which, in the normal course, requires treatment as In-
patient for a minimum period of 24 hours in a Hospital/Nursing Home.

The policy seeks to meet the hospitalisation expenses required by a person in

the normal course. Though in many cases hospitalisation is a requirement, the
Insurers would not cover them as they are either not required by the public in
general or would not amount to insurance or would require a higher premium to
 cover the risk- hence, the concept of exclusions. Exclusions define those
procedures / ailments that will not be covered by the Health Insurance Policy.

The Exclusions are imposed in the policy in order to:

 Restrict cover to normal risks required by average insured
 Exclude losses of extra-ordinary/ catastrophic nature
 Define & clarify scope of cover
 Exclude risks which require additional inputs
 Exclude risks of frequent nature
 Exclude intentional losses
 Exclude inevitable losses
 Exclude commercially un-insurable

Common Exclusions in Health Insurance Policies

The general exclusions that are found in most health insurance polices in India
are listed below. Please do read your policy document to know the exact list of
exclusion applicable to you:
 Pre-existing diseases
 Any illness in contracted during the first 30 days except accidents
 First year/ Two Years /Four Years exclusions for certain ailments
 Preventive Medical Expenses like Vaccination, Inoculation etc.
 Cosmetic, aesthetic treatment
 Circumcision, Change of Life
 Plastic surgery unless due to accident or part of treatment of an ailment
 Congenital External diseases/conditions
 Treatment for Sterility, Infertility, Assisted Conception
 Venereal Diseases, Sexually Transmitted Diseases
 Intentional self injury, Suicide, Psychiatric/Psychosomatic Disorders,
Alcohol or drug misuse or abuse.
 Surgery for correction of eye sight, cost of contact lens, spectacles,
hearing aids, CPAP and other durable medical equipments.
 Dental treatment unless arising out of an accident and unless the
treatment requires inpatient admission.
 HIV, AIDS and related conditions.
 Genetic Disorders
 Stem Cell Treatment
 Injuries sustained whilst being engaged in a Hazardous Activity or
Hazardous Sports
 Hospitalisation primarily for Diagnostic/evaluation purposes without active
line of treatment during hospitalisation.
 Medical Expenses for illness or injuries which are treated on an Out
Patient basis.
 Mere Hospitalisation of 24 hours or more does not guarantee admissibility
of the claim. Any treatment or procedure usually done in OPD ,even if converted
to Day care Surgery procedure or as inpatient in Hospital for more than 24
hours, will not be payable.
 If expenses are unreasonable and unnecessary, the claim is likely to be
rejected.
 Medical Expenses incurred in a Hospital or Nursing Home not meeting the
criteria as defined will be outside the scope of cover. Check with the Hospital
whether it meets the criteria before Hospitalisation.

The above list is indicative and not exhaustive. Exclusions may differ from policy
to policy and Insurer to Insurer.

Proper Utilisation of the Policy Benefits

We are all concerned about “Health” - our own, and that of our dear & near
ones. Not all are blessed with perfect health. We do suffer from sickness and
meet with accidents in spite of taking all steps, precautions, preventions. A
majority of our ailments are minor and seasonal. They are either cured on their
own or require very little medical intervention. A few of them, however, require
treatment in Hospitals or Nursing Homes as In-patients and we should use our
health insurance cover only then.

 Use the Health Insurance benefit only for yourself or your covered
dependents. Using your Health Insurance for anyone not covered is tantamount
to financial misappropriation – you may find that your Health Insurance cover
is exhausted when you actually need it.

 Act as a prudent insured at all times – please do not treat your insurance
benefit as if it were your debit card. Do not use Health Insurance for trivial
reasons.

 Use your Health Insurance cover only when you really need it – do not
waste it on minor ailments that can very well be treated as an outpatient.

 Meet the doctor of your choice and seek opinion on the treatment line. It
is always beneficial to take a second opinion when major treatment such as
surgery has been suggested.

 Enquire about the cost of the procedure and quality of service in various
places before you decide on your hospital of choice. Remember that ‘expensive’
is not always directly proportional to ‘quality’. In healthcare, there are a whole
lot of small hospitals doing quality work. A number of procedures also do not
require hospitalisation even for a day – there are a good number of day
care Centers carrying out these surgeries. You can save on the cost of
hospitalisation as well as save the trouble of being in the hospital unnecessarily.

 Avoid admission to luxury category rooms/ wards – All the expenses – not
only the room charges but all other expenses go northwards. Health Insurance
is for necessary and reasonable treatment and not for enjoying luxuries!

 Always keep in mind that the more you use your Health Insurance
cover today, the higher will be the premium you have to pay to
remain covered tomorrow – Health Insurance cost can become
prohibitive and unaffordable for you / your Employer. This is a point
worth pondering on!
 Prevention better than cure
The pattern of disease is shifting from a world of communicable & infectious
diseases to a world of non-communicable & life-style diseases. This has created
a great long term burden on the cost of healthcare. The only thing that will help
is prevention and management. Non-communicable and life-style diseases are
cancer, arthritis, cardiac ailments, diabetes, hypertension, obesity, etc. A whole
lot of these can be prevented by judicious changes in lifestyle and a lot others
can be managed, again, by lifestyle changes. It must be remembered that these
diseases, unlike communicable / infectious diseases will be with us for a lifetime
and can make the quality of life miserable.
Some lifestyle changes that all of us can work on:
• Regular exercise – yoga, aerobics, jogging, swimming, etc.
• Balanced diet – avoid junk foods
• Avoid smoking, excessive alcohol, drugs
• Mental relaxation techniques such as meditation
• Laughter – the best medicine
• Regular health checks to catch them early
The list is endless – we know about these – but doing is what matters!

Defined benefits or caps on surgical procedures

Certain Health Insurance policies may define limits that can be paid out for
certain named procedures. Any amount over and above the defined benefits will
have to be borne by the policy holder / insured. For ex. if the policy defines that
the defined benefit / cap for cataract is Rs. 20,000, the maximum claim
settlement value for cataract claim will be Rs. 20,000 although the sum insured
may be any amount.

Advance intimation
One of the very basic requirements of insurance is called ‘Claim Intimation’. It
simply means intimating the TPA or the Insurance Company that a claim is going
to be made in the near future. Some of the policies indicate a time frame of 24
hours or 7 days from the date of admission, most of the policies require that
intimation has to be lodged immediately on admission. Non-compliance to this
may make your claim inadmissible.
Studies have shown that a majority of the hospitalizations are planned
hospitalizations. Therefore, the insured is in a position to give Advance Claim
intimation. This has several advantages:
 The TPA gains prior knowledge that a claim is in the pipeline
 The TPA can prepare itself in advance to process your claim
 The TPA can arrange to get any information, from the Insurance
Company, that it may be required to process your claim, thus preventing delay
in processing after you submit the documents.
 The TPA can help negotiate appropriate rates for your treatment at the
hospital.
 The TPA can intimate you in advance about the admissibility of the claim,
so that you can prepare yourself for the financial burden that you face.
 Claim intimation generally requires the following information to be provided:
• Nature of illness / injury (can be in your own words)
• Nature of treatment (can be in your own words)
• Hospital name and location
• Probable date of admission and expected length of stay in the hospital
• Name of the treating doctor / Consultant

According to Health Insurance what is a hospital

A hospital / nursing home is an institution in India established for indoor care
and treatment of sickness and injuries. The hospital or nursing home should be
registered with the appropriate local authority and it should be functioning under
the supervision of a registered and qualified medical practitioner. If not, it should
satisfy the following criteria:
• It should have at least a minimum of 15 inpatient beds (10 beds in C class
towns)
• It should have fully equipped operation theatre in case surgeries are being
carried out
• It should have fully qualified nursing staff under its employment round the
clock
• Fully qualified doctors should be available round the clock.
A place of rest, a place for the aged, a place for substance abuse rehabilitation,
a hotel, etc. that may be termed as ‘hospital / nursing home’ does not fall under
the health insurance definition of hospital / nursing home.

Claim under Multiple Policies

 Benefit Policies: In case of multiple policies which provide fixed benefits, a
policy holder can claim in one or more policies and the insurer will make a claim
payment irrespective of the payments received under other similar policies.
 Indemnity Policies : In case of multiple policies that indemnify health
expenses, if there is a claim, the policyholder will have the right to choose an
insurer for lodging the claim and irrespective of the fact whether other policies
are in place, insurer must pay the claim as long it is falling within its terms and
conditions. If there are amounts that are disallowed under the earlier chosen
policy, then the insured can claim those amounts from another policy and the
insurer is liable to settle this claim as per the terms and conditions of this policy.
 Pre-Authorisation Guide

To ensure prompt approval of cashless requests and

settlement
Steps to be followed

 Submit the pre-authorization request on the latest form circulated by the

TPA. Earlier forms do not contain fields now mandated by the IRDA. Latest Pre-
authorisation Request Form.
 Ensure that all the columns in the pre-authorization request form are duly
completed LEGIBLY
 Avoid use of abbreviations while recording ailments/ procedures – this
would take more time for the approver to decipher / understand what exactly it
is
 Obtain the signature of the patient/ attendant in the form at the
appropriate place provided in the form
 Do not suppress any information on the history of the ailments/ co-
morbidities/ alcohol status
 Always go by the tariff that you have filed with the TPA for the various
charges being claimed
 If you have not filed your tariff for the procedure being carried out (where
it is a new procedure introduced) file the tariff for the procedure immediately
with the TPA network team
 Submit the pre-authorization request a couple of days in advance for
planned admissions
 Liaise with the pre-authorization team to know the status of the request
 To ensure prompt attention and real-time status updates use online pre-
authorisation submission model instead of the fax mode
 Submit the documents as listed below during the preliminary pre-
authorisation/ final pre-authorisation process to avoid shortfall
 In the event of a shortfall raised by the approver, promptly submit the
same
 If the documents as called for in the shortfall request are not submitted,
the TPA is authorised to close or the reject the Pre-authorisation request.
 On receipt of the approval, please check if the approval is subject to any
conditions like
a. Room rent cap per day
b. Any other restrictions linked to the eligible room limit
c. Ailment/ procedure cap
d. Co-pay to be deducted

 There will be standard conditions as below. Understand their significance –

do not over-look:
a. This authorization is valid only at the above hospital, for the
diagnosis and treatment approved, provided admission falls within the date of
admission as above. For any change in date of admission, diagnosis or the
 procedure/ treatment specific approval has to be obtained failing which this
approval will be null & void.
b. For enhancement of expenses approval must be obtained before
patient is discharged
c. Vidal Health Insurance TPA is not liable for payment under this
authorisation if the information provided during pre-authorization/ or the claim
documents submitted by the hospital or insured is incorrect / revised
d. Cashless access for hospitalization is only a facility extended by TPA
subject to terms and conditions of the policy. Vidal Health Insurance TPA does
not guarantee the quality, availability or outcome of treatment.
e. Denial of cashless access is not to be considered in any way as a
denial of treatment.
f. Please collect all non-admissible expenses from the patient. Please
visit our website for the list of non-admissible expenses.
g. In case of maternity related hospitalization (a) claim will not be
admissible if the person has two or more living children (b) well-baby care
related charges to be collected from the patient.
h. The claim settlement would be as per the tariff /discounts
contracted in the network agreement
i. The following claim papers should be submitted within 7 days
from the date of discharge of the patient: (a) photo ID proof of patient (b)
cashless approval copy with the voucher portion duly signed by the insured
patient (c) detailed discharge summary (d) all investigation reports (e) operation
notes (f) hospital final bill (g) detailed break up bill (h) copy of receipt given to
the patient for the amount paid by him/her (i) copy of separate receipt issued
for co-pay collected. If co-pay receipt is not submitted the claim will be
denied and no liability under this authorisation attaches to us.
j. The above payment is subject to applicable TDS.
k. If the insured is found to be an HIV/ AIDS patient and if the same is
not disclosed during the cashless facility obtained, the authorisation shall be null
and void and no liability attaches to this authorisation.
 Follow the IRDA circulated list of non-admissible expenditure to be
collected from the patient before discharge. This will reduce the time taken by
the TPA for processing the bills
 Once the final authorisation request is sanctioned,
a. Keep the documents ready to be submitted for settlement
b. Obtain the signature of the patient/ attendant in the voucher
portion of the final approval letter
c. Obtain the signature of the patient on the Discharege Summary
and the Hospital Bills (at least the Main Bill)
d. Obtain the Claim Form duly completed and signed by the Patient
tobe submitted to us along with Claim Documents

e. Collect from the patient any other amount deducted by the TPA
 Submit the claim papers as detailed below to the TPA on the next day for
their immediate processing for settlement
 Maintain a set of papers submitted in a claim folder till such time the
settlement is received. This will avoid your running around for the document
should the TPA seek another set or clarification on the claim submitted
 A couple of days after claim submission, Check with the TPA whether they
have received the claim documents for settlement.
 To avoid misplacement/ non-delivery of the claim documents, ensure that
you submit the papers through personal/ office courier weekly 3 times
 Do not bunch all the papers submitted on a day together. Obtain
acknowledgement for each case paper separately quoting the pre-authorization
number
 Once the settlement is received from the TPA please update your account
and keep reconciling your bills receivable account – TPA-wise
 Check bills receivable with the bills pending settlement at the TPA-end
monthly
 Should the settlement made be different from the amount approved, seek
clarification from the TPA and square up your account – either by writing-off the
amount deducted if you agree with the deductions and if do not agree with the
deduction pl follow-up the same and close each issue within a month. Please do
not stand on ego for resolving the issue and do not keep carrying forward the
bills short received/ short settled for ever. The Insurers cannot reopen the cases
once the financial year is closed and TPA’s cannot settle such cases.
 Where you find the TPA has not received the claim documents sent for
settlement of your claim, kindly submit one more set of papers – marking them
‘duplicate’ along with a copy of the POD/ courier / postal receipt
 Under certain circumstances the papers submitted to the TPA may get lost
at their end due to mix up with other documents. Should TPA seek one more
copy, please submit another set of documents duly marking ‘duplicate’.
 Should the TPA deny cashless facility in respect of a request without
assigning any reason, pl do not insist on TPA giving the reason. Advise the
patient to settle the bill and submit the papers to the TPA for a possible
reimbursement.
 In the event a claim facilitator is sent for verification of the case
documents and collection of the same, kindly co-operate

Documents to be submitted
For Preliminary aproval
 Pre-authorisation form duly completed in all respects
a. Signed by the insured/ patient
b. Preferably the latest form – to adopt the IRDA designed form for all
TPAs uniformly
 ID Proof
a. TPA ID card
b. Any other additional card like:
i. Voter’s ID
ii. Unique identification number
iii. DL
iv. Pan card
v. Employment ID card
 Admission Notes – in cases where the patient is already admitted prior to
seeking pre-auth request
 Investigation Reports – USG/ haematology/ MRI/ x-ray - etc for
a. Investigations undergone prior to hospitalisation
i. Possibly at the same hospital or
ii. Outside the hospital
 b. Investigations undergone immediately on admission prior to sending
the request
i. Possibly at the same hospital or
ii. Outside the hospital
 Blood Alcohol Reports – if available (especially for accidental injuries)
 Consultation Papers
a. OPD consultation paper, if any
b. Outside the hospital
c. Referral from a physician, if any
 Medico-legal papers for accident cases
a. MLC report
b. Police FIR – if available

Documents required for final approval

 Enhancement request with justification for enhancement of the amount –

quote the Preliminary Authorisation Approval Letter number
 Report on any changes in the Final Diagnosis/ change in the treatment
administered/ history of the ailment/s
 Detailed Discharge Summary indicating
a. The Primary Diagnosis for which treatment has been administered
– its history
b. Secondary Diagnosis for which (possibly) treatment has been
administered – their history
c. Co-morbidities – their history
d. Symptoms/ complaints on admission
e. Tests conducted
f. Treatment administered
g. Discharge advice
 Death Summary (instead of Discharge Summary) where the patient has
passed away during hospitalisation
 Investigation Reports – for all tests conducted – excluding the reports
already sent for Preliminary Authorisation
 Histopathology Report – wherever possible
 Operation Theatre Notes – where surgery is performed
 MLC report/ FIR for accident cases – if not submitted at the time of
Preliminary Authorisation
 Sticker for the implants used
 Supporting invoice for the implants used
 Hospital Main Bill duly signed by the patient
 Break-up bill for the hospital Main Bill – duly signed by the patient
 Copy of the separate receipt for the co-pay amount collected
 Copy of the detailed bill for the amount collected from the patient for the
other non-admissible amounts
 Copy of the receipt for the other non-admissible amounts collected from
the patient
 Preliminary pre-authorisation approval letter duly signed by the patient

Documents required for settlement for cashless approved

 Preliminary Pre-authorisation request duly signed by the patient and the

treating doctor - original
 Copy of the Preliminary Pre-authorisation approval letter duly signed by
the patient
 Copy of the final enhancement approval letter duly signed by the patient
in the voucher portion
 Original enhancement request with justification for the enhancement of
the amount
 Report on any changes in the Final Diagnosis/ change in the treatment
administered/ history of the ailment/s
 Admission Notes – certified copy
 OPD case papers/ consultation paper/ referral letter submitted during the
Preliminary Pre-auth – certified copy
 ID proof – submitted during Preliminary Pre-auth process - copy
 Detailed discharge summary submitted for final enhancement - original
 Death Summary (instead of discharge summary) where the patient has
passed away during hospitalisation - original
 Investigation Reports in original – done prior to admision and during
hospitalisation submitted during Preliminary Authorisation as well enhancement
 Histopathology Report in original
 Certified copy of operation theatre notes – where surgery is performed
 MLC report/ FIR for accident cases – certified copy
 Sticker for the implants used - original
 Supporting invoice for the implants used – certified copy
 Hospital Main Bill duly signed by the patient- original
 Break-up bill duly signed by the patient for the hospital Main Bill - original
 Copy of the separate receipt for the co-pay amount collected
 Copy of the detailed bill for the non-admissible amounts collected from the
patient
 Copy of the receipt for the amount collected from the patient for the non-
admissible amounts
 Your covering letter forwarding the claim paper – use separate letter for
each case

Comprehensive Claim Management

Reimbursement of the hospitalization expenses can be claimed where Cashless

Hospitalisation facility is not availed or treatment is availed in a Non-network
Hospital. You will have to settle the hospital bill, collect all original hospitalisation
documents and submit the documents to our office for their scrutinizing the
same in terms of the policy and check the admissibility or otherwise of the
claim/ expenses.

 Reimbursement claims may be filed in the following circumstances:

a. Hospitalization at a non-network hospital
b. Post-hospitalization and pre-hospitalization expenses
c. Denial of preauthorization on application for cashless facility at a
network hospital
 Reimbursement claims can be submitted to us through registered post /
courier or can be handed over at any of our Branches.
 One of the very basic requirements of insurance is ‘Claim Intimation’. It
simply means intimating us or the Insurance Company about the
hospitalisation. Some of the policies indicate a time frame of 24 hours or 7 days
from the date of admission, most of the policies require that intimation has to be
lodged immediately on admission. Non-compliance to this may make your claim
inadmissible.
 The documents that you need to submit for a hospitalization
reimbursement claim are:
a. Original hospital final bill
b. Pre-Numbered / Printed Receipts for payments made to the hospital
c. Complete break-up of the hospital bill
d. Original Detailed Discharge Summary
e. All Investigation reports
f. All medicine bills with relevant prescriptions
g. Operation Theatre Notes in the event of a surgery performed
h. Sticker for the Implant, if any, used during surgery
i. A copy of the Invoice for the implant, if any, used during surgery
performed
j. Original duly completed and signed claim form
k. Duly completed and signed Medical Practitioner’s Form
l. Copy of our ID card or current policy copy and previous years’ policy
copies if any
m. Company Employee ID card if you and your family are insured through
your employer
n. Documents for National Electronic Fund Transfer (NEFT)
i. NEFT Format giving details of the Bank Account where you need
the claim amount to be transferred
ii. A copy of the page of the Bank Pass Book containing the Account
Number & the Name/ Address of the Account Holder.
iii. A cancelled Cheque for the above Account in to which the claim
amount has to be transferred
o. Covering letter stating your complete current address, contact address
if available and the list of documents attached.
 The documents that you need to submit for a Post-hospitalization or a
Pre-hospitalization claim are:
a. Copy of the discharge summary of the corresponding hospitalization
b. All relevant doctors’ prescriptions for investigations and medication
c. All bills for investigations done with the respective reports
d. All bills for medicines supported by relevant prescriptions
e. NEFT Documents as above. (If you have furnished the NEFT Documents
for the main hospitalisation claim earlier, you want the amount be
transferred to the same Bank Account, Please furnish the Claim Particulars for us
to pick up NEFT Details there from.)
 Once the reimbursement claim is received, it is processed. Our medical
team will determine whether the condition requiring admission and the
treatment are covered by your health insurance policy. They will also check with
all the other terms and conditions of your insurance policy. All Non-admissible
Expenses will be disallowed.
 The policies stipulate a period from the Date of Discharge within which the
claim documents have to be submitted. Submission of claim papers after the
stipulated period could lead to denial of the claim. Normally it is 7 days from the
date of discharge for hospitalisation claim and for Post-hospitalisation it is 7 days
 from the date of completion of the post-hospitalisation treatment. Please check
for the time frame for submission of the claim papers. In case the claim papers
are submitted beyond 7 days from the date of discharge the claim is liable to be
denied as per the policy terms. Hence, ensure compliance to the time frame
without fail.
 Based on the processing of the claim, a denial or approval is executed. In
case of approval, settlement is made by transferring the approved amount to
your Bank Account. We will also send you the settlement particulars along with
the computation sheet to the address mentioned in your health insurance
policy. In case you have been insured through your Company, the cheque will
be dispatched to the address based on instructions received from your company.
 In case we require additional documents we may send you a Shortfall
Letter. Kindly comply with the requirements within the stipulated time. In case
you do not submit the required documents within the stipulated time, after 2
reminders we will reject the claim and send the Denial Letter. Once the claim is
denied as above, you will forfeit your right to the claim.
 In case your claim is denied, the denial letter is sent to you by courier /
post quoting the reason for denial of your claim. In case you have been insured
through your Company, the denial letter will be dispatched based on instructions
received from your company.
 In the event you are aggrieved with the settlement or the denial of the
claim, you may kindly represent your case to our Grievance Cell. You may also
refer the matter to your Insurer’s Grievance Cell.
 If you are not satisfied with the redressal of your grievance either through
our Grievance Cell or that of the Insurer, you may present your case before the
Insurance Ombudsman.
 Process Flow Chart

Cashless Procedure
If you are planning hospitalisation
You need to do the following …

Fill the Pre-Authorisation Form, available with the Network Hospitals upon
showing Vidal Health Card. This can also be obtained from any of the Vidal
Health Insurance TPA Pvt Ltd branch offices or can be downloaded from this site.
 Submit/Fax the Pre-Authorisation Form at our local branch office 4 days in
advance.
 If your hospitalisation is authorised, then ensure:

a. You pay for non-medical expenses and

b. Sign the relevant documents including a claim form before leaving the
hospital/ getting discharged

 If your hospitalisation is rejected, then you can then submit a claim for
reimbursement purpose at the Vidal Health Insurance TPA Pvt Ltd Branch office
near you. (See Claims Settlement Procedure)

REMEMBER! - Vidal Health Insurance TPA Health Card issued to you is

NOT a Credit Card, it is just complementary to your Mediclaim policy,
and only on verification of your coverage, will you be given CASHLESS
treatment Your cashless treatment will begin at the hospital, only after
the hospital receives Authorisation confirming the same.

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 them to intimate Vidal Health Insurance TPA Pvt Ltd
 If your hospitalisation is authorised, then ensure:

a. You pay for non-medical expenses and

b. Sign the relevant documents before leaving the hospital/ getting
discharged.

 If your hospitalisation is rejected, your treatment will be continued at the

hospital. After discharge, you can then submit a claim for reimbursement
purpose at the Vidal Health Insurance TPA Pvt Ltd Branch office near you. (See
Claims Settlement Procedure)

Claim Settlement Procedures

 To settle your claims, it is essential that every policy holder go through a 3 step
cycle which is called
(1) Claim Intimation/Notification (2) Claim document procurement and (3) Claim
submission.

(1) Claim Intimation/Notification

Under Mediclaim, in case of hospitalisation, the policy holder should primarily
ensure that the Vidal Health Insurance TPA Pvt. Ltd. is informed within 7 days of
the hospitalisation. This preliminary notice should be submitted to Vidal Health
Insurance TPA Pvt. Ltd. prior to the claim and the same should contain the
following particulars:
 Vidal Health/TTK HTPA Card Number or Policy Number
 Certificate Number
 Nature of illness and/ or injury
 Name and address of the attending physician
 Name of the hospital or nursing home, attending doctor
 Bed number in the hospital

(2) Claim Document Procurement

 Hospital Bill with Receipt for payment along with the break up signed by
the policy holder.
 In case of surgeons / consultants bills, kindly insist on a stamped,
preferably numbered receipt, Doctor's prescription and medicine bills.
 Discharge summary sheet from the hospital.
 Pathological reports and other investigation reports along with the doctor's
authorization.
 Other relevant details and documents connected to hospitalisation.

(3) Claim submission

All the above need to be enclosed along with the Claim Form that can be
obtained from the nearest Vidal Health Insurance TPA Pvt. Ltd. office or can be
download by clicking on the downloads in left menu.
This claim form must be filled fully and sent to the nearest Vidal Health
Insurance TPA Pvt. Ltd. office along with the following documents in original.

Note: Only expenses related to hospitalisation will be reimbursed as per the

policy taken. All non-medical expenses will not be reimbursed.
 Frequently Asked Questions

 Why did TTK Healthcare TPA’s name change to Vidal Health

Insurance TPA?
TTK Healthcare TPA has been acquired by Vidal Healthcare founded by Mr. Girish
Rao. This was a strategic move by Vidal Healthcare to become an integrated
Healthcare solutions Organization by creating synergy between the TPA and
wellness businesses.

 What is the procedure to avail cashless facility?

Customer needs to drop into a Vidal Health Insurance TPA Pvt. Ltd. network
hospital to give a copy of his/her Vidal Health Insurance TPA ID card and
Identity proof at Hospital reception. Pre-authorisation form has to be filled which
has two parts. Part 1 needs to be filled by the patient or the patient’s family and
part 2 needs to the filled by the Hospital authority/Treating doctor. The
completely filled form should be faxed or mailed to Vidal Health Insurance TPA
Pvt. Ltd (respective branches). Once pre-authorisation form is received
by Vidal Health Insurance TPA Pvt Ltd., the case will be processed within 4 hours
and the initial authorization letter (approved or rejected) will be faxed/emailed
back to hospital by Vidal Health Insurance TPA Pvt. Ltd.
Note:-
For planned hospitalization: - Pre-authorisation form to be sent before 48 hours
of hospitalization.
For Emergency: - Pre-authorisation form to be sent within 6 hours from the time
of admission.

 What is the TAT to process the enhancement (Final approval)?

On the date of discharge hospital team have to send the final bill with break up
and discharge summary to Vidal Health Insurance TPA Pvt Ltd. After the receipt,
within 2 hrs the enhancement (as per policy limits) will be processed after
deducting the non medical expenses (paid by the patient) and approval letter
will be sent to hospital fax or email.
Note: - Co pay (if applicable) has to be paid by the Policy holder
Some of the Hospitals are Preferred Provide Network (PPN), Gipsa and Hospital
tariff, if cashless is taken in those hospitals the final approval will be as per the
respective tariff.

 What is the TAT to process the pre-authorisation once shortfall

query is responded?
Once the shortfall is responded, within 2 hours the case will be processed.

 What is the procedure to cancel the cashless approval?

Hospital team needs to send the letter/fax/email to Vidal Health Insurance TPA
Pvt. Ltd., asking them to cancel the approval. The cancellation letter will be sent
to hospital within 2 hours.

 Is there any time limit to submit the Pre-authorisation request?

Yes. If it is a planned hospitalization then the pre-authorization request needs to
be sent before 48 hours from the date of admission. In case of emergency the
pre-authorisation request needs to send within 6 hours from the time of
admission.
 Do I need to pay any amount to the hospital while getting
discharged for Cashless hospitalisation?
Yes. The policy holder needs to pay the non medical expenses and the co-pay
amount (if applicable). He will need to pay the difference amount (difference
between the final bill and approved amount).

 What are Non-Medical expenses?

Non Medical expenses are: Admission fees, Registration fees, gloves, blade,
water bed, food & beverages, extra bed etc.,

 Is there any minimum time limit for stay in the hospital?

Minimum 24 hours of hospitalization (if not day-care) with active line of
treatment is required for cashless treatment
However, there are a few specific ailments specified in the policy which can be
covered even though the period of hospitalization is less than 24 hours. Such as
Dialysis, Chemotherapy, Radiotherapy, Eye Surgery etc.,

 What is Cashless Rejection ?

Rejection will be done as per the policy terms and coverage, the below are the
few examples for rejection.
a. If hospitalization is for observation & investigation purpose
b. If any particular aliment/disease/treatment is found not covered under policy
term and condition
c. If found that the treatment can be done under OPD basis
d. If found that no active line of treatment is available
e. If Shortfall and the policy holder has not responded within the given TAT
f. If policy is invalid
g. Rejection of cashless is not a denial of treatment

 What if the cost exceeds the level of hospitalization insurance

cover ?
In such a situation the policy holder will be liable to pay the difference amount.
We will inform the hospital about the policy holder’s eligible amount and hospital
will recover the amount over and above the credit amount from the policy holder
directly.

 What are the different types of Claims ?

Member Claim and Network Claim (for Hospital)

 How will I be intimated about the Claim ?

Policy holder has to intimate Vidal Health Insurance TPA Pvt. Ltd., before
sending the claim documents if he/she wants to claim after discharge, Intimation
has to be given within the TAT as per the insurance company.

 What is the procedure of Reimbursement?

Policy holder will need to download the claim form No 9 from our
website www.vidalhealthtpa.com. The claim form contains 4 pages which
includes medical certificate also. The medical certificate needs to be filled in by
the Treating doctor with hospital seal and doctor’s signature. The policy holder
should fill the claim form and should attach all his original bills and send a
courier to Vidal Health Insurance TPA Pvt. Ltd(respective branches).
 Note: - The claim documents has to reach Vidal Health Insurance TPA Pvt. Ltd.,
within the TAT as per the Insurance company TAT
For all United India Insurance policy holder ECS is mandatory, they have to send
ECS form along with the cancelled cheque with the original claim documents.

 What is the TAT to process the reimbursement (Claim)?

Once Vidal Health Insurance TPA Pvt. Ltd., receives the claim documents, Claim
will get processed within 21 working days

 Once the claim is processed within how many days I will receive
the cheque?
Cheque will be dispatched within 7-10 working days from the date of approval.

 How does Vidal Health Insurance TPA assess the claim?

Vidal Health Insurance TPA Pvt. Ltd. will assess the validity of the claim based on
the documents submitted, validate the policy, validate the treatment undergone
and settle the claim within the claim settlement parameters. In case of claim is
not adhering with parameters, the case would be rejected.
Vidal Health Insurance TPA Pvt. Ltd. will correspond with you within 7 days of
Claim receipt -
If Documents are not completed then Vidal Health insurance TPA Pvt. Ltd. will
request for the shortfall documents

 If Claim is rejected then a Rejection Letter will be sent

Note: If any bills and receipts are not supported by valid documents, then the
claimed amount of that bill will not be processed.

 Will i get intimation for my claim status?

Yes, you will be intimated on your claim status to your updated email id from our
database.

 How can I check my Claim Status?

You can login to your account in our web portal or you can call our call center to
check the claim status.

 What are the documents that I should submit for reimbursement?

You should submit the entire set of ORIGINAL DOCUMENTs like
a. Claim form duly signed
b. Vidal Health Insurance TPA card (photo copy)
c. Identity Proof (photo copy)
d. Discharge summary with seal & signature of the hospital authority
e. In-patient bills
f. Doctor’s prescription
g. Pharmacy bills with break ups
h. Investigation reports like MRI, ECG, CT scan, and X-Ray etc
i. Laboratory reports
j. Paid receipt with hospital seal & signature
k. Hospital registration copy (if required)

 What are shortfall documents (S/F)?

Shortfall documents are those which are not submitted by the claimant, which is
mandatory for further claim process.
 Where and how can I send the Shortfall Documents?
You can send the shortfall documents to respective Vidal Health Insurance TPA
Pvt. Ltd. branch through post/courier or by walking in to respective branch.

 What is the TAT for submitting the Shortfall documents?

You should send within 7 working days from the date of receiving the S/F
query/letter.

 What is disallowed amount?

The amount which is not approved is disallowed amount such as Non medical
expenses, no proper bill break up, Lab report not submitted aliment capping,
exceeds Sum insured / aliment limit Etc

 What is Claim Rejection?

Refer cashless rejection, a part from those the below are the few reasons for
claim rejection
Claim docs not submitted within the given TAT
Claim intimation not given
Date of inception is greater than date of admission
Fraud Case

 What is Day-Care Surgeries?

Day Care surgeries are those which do not require 24 hours of hospitalization
such as Cataract (Eye) surgery, Dialysis, Kidney stone removal, Chemotherapy,
D&C etc.

 Day care surgeries are payable or not?

Depending on Insurance policy some of the day care surgeries are payable
according to term and conditions.

 How can I download Vidal Health Insurance TPA card soft copy (E
Card)?
You can login to your account in Vidal Health Insurance TPA web portal and
download E Card or call the call center and place the request.

 I am using a TTK Health card ; will my card be accepted for

cashless hospitalization / Reimbursement?
The TTK Health card both Physical and E-cards will still be valid at all
network hospitals for Cashless Hospitalization. All the hospitals are
informed to accept TTK cards also.

 Will Vidal Health Insurance TPA’s phone numbers, fax and e-mail
addresses are the same?
All the contact details have been updated in the website. Please note
that our e-mail will now read name@vidalhealthtpa.com instead
of name@ttkhealthcareservices.com
Wellness

Wellness is not just about living a healthy life, but also feeling good from within.
It is a multidimensional (physical, social, intellectual, emotional and spiritual)
state of being, describing the existence of positive health in an individual as
exemplified by quality of life and a sense of well-being. It is a progression
towards being conscious and making choices to attain a healthy life.

Wellness is a progression because the scope for improvement is perennial in

which we continuously seek knowledge to take the best course among many
options available

Doc ‘Round The Clock is a service that will help you assess your health related
symptoms. This provides you with an 24/7 Telephonic Helpline for Medical
Advice. As our valued Health Insurance Administration customer, we want to
make sure that you have access to this symptom-based Intelligence System –
‘round the clock.

The service gives you direct access to a qualified doctor over the phone. Key
features are:
• 24/7 Service
• Available Across India
• Simple Question & Answer Based Tool
• Symptom-based Intelligence System
• Telephonic Medical Guide

There is a unique phone number which will instantly connect you to the doctor
once you validate your account. You can now call 080-49101010 for any queries
you have related to your health.

Doc ‘Round the clock clearly

• Preserves your peace of mind
• Promotes better understanding of any health problem
• Prevents unnecessary health anxiety for you and your loved ones
• Protects you by providing instant access to medical assistance. Anytime.
Anywhere

This telephonic medical guide provides first-hand assistance to you and to all
your dependents who are covered under your corporate insurance cover.

Second Opinion
 Medical Second Opinion has been gaining popularity whereby the beneficiary’s
medical records are reviewed in confidence by a medical specialist and opinions
are shared on the suggested lines of treatment.

We´ll put you in touch with the leading specialists and medical institutions,
giving you comprehensive service that´s easy to access, and personalized to
your needs.

Please fill up the below form in full and submit. Your query will be processed only
if all the relevant information is given. Please avoid the use of abbreviation. The
information provided will be kept completely confidential.

Overview

"Here since 2002, Vidal Health Insurance TPA Pvt. Ltd has been a frontrunner in
providing hurdle-free third party administration for health
insurance. Vidal Health Insurance TPA Pvt. Ltd is among the nation's leading
providers of Third Party Administration (TPA) Service. We continuously strive to
set benchmarks in 3 main focus areas of our functionality-Customer, Innovation
and Operational Excellence."

IRDA LICENSE

Customer Focus
 24/7 dedicated helpline and corporate help desk for customer support.
 Help desks at Hospitals to enhance service for customers.
 Patient empowerment through monthly newsletters and health talks.

Innovation
 Online enrolment and issuance of e-cards.
 Customised network solutions to reduce the claim costs.
 SMS/Email alerts that helps in tracking preauthorisation/claims requests.
 Health Insurance Portfolio Analysis (HIPA) – a customised report that
provides insights on your health insurance portfolio to help you analyze better.

Operational Excellence
 We achieve the fastest turnaround time for all insurance transactions in
the industry.
 We respond to over 1 million calls in a year catering to over 21 million
lives with an annual claim volume of 6.17 lacs.
 Extensive National reach with cashless facility with annual volume of
4.81lacs, available at more than 600 locations.
 Robust technology platform supports wide spectrum of services to growing
volume of customers with wide range of health insurance products.
 Skilled and trained manpower is the biggest asset of Vidal Health
Insurance TPA Pvt. Ltd., and its core competence lies in superior claim
management, fraud management, advanced analytics while ensuring quality
care, promoting preventive care & wellness programs, advanced analytics and
predictive modelling.

About Us

Vidal Health Insurance TPA Pvt Ltd was established in March 2002 with the
mission to provide top quality TPA services to Health Insurance policyholders
and be the most preferred TPA in India. We are licensed by IRDA (Insurance
Regulatory & Development Authority - License No. 016) and have been
empanelled by leading insurance companies, both public sector and private,
across different regions of the country.

We, at Vidal Health Insurance TPA Pvt Ltd, believe customer satisfaction is
of utmost importance and constantly strive to achieve the same.

Our Registered & Corporate Office is located at

First Floor,
Tower No. 2, SJR iPark,
EPIP Zone, Whitefield,
Bangalore - 560066,
Phone No : +91 80 28004100
Fax: 1800-425-2626
CIN N0.U85199KA2002PTC030218
GIPSA, a group of four PSU to standardise rates for
around 42 medical procedures across various
categories of over 4000 hospitals for settling cashless
claims.but is looting and cheating patient by GOOF-up
with hospital and TPA. 1. GIPSA Rates in package is
almost 4 times the rate that any patient can do a
procedure under cash payment in same hospital. Cash
payment rates r cheapest since in open market
hospital faces completion with other hospital. 2.
There is a confusion first, if (a). GIPSA decided
arbitrary rates are same across all categories of 4000
hospitals in country or (b) where the arbitrary rates
are same across all categories of big or small hospital
in any metro or that particular town, In both above
case this is against public interest as the rates r. kept
as high as possible to suit the costliest hospital. But
this benefits maximum to the lower category of
hospital. In third (C) case, if GIPSA negotiates raters
for that particular hospital but same for all patient in
that hospital who r taking cashless treatment for that
particular medical procedure,ly this is even worst
situation as there is maximum chance of hospital
bribing GIPSA to get highest rates for any particular
medical produce to be performed in cashless. 3. even
if a poor patient takes a low category room still he
ends u paying for the highest category charge that a
patient of highest suit room pays for his surgery..
GIPSA package is same for all whether a patient has
paid premium for a triple sharing room(thus a lower
premium) or a single sharing room(higher
premium)they are entitled to same amount of money
being released by their insurance company to the
hospitals for a particular procedure if the insurance
amount is same..Fore example whether a patient
delivers in in shared room or a single room ,hospital
and doctor will get a total of Rs 35000,which includes
bed charges,medicines,disposables,surgeons charge
and all other expenses. Thus GIPSA loots the poor. 4.
GIPSA has prepared different category packages for
42 (surgery) medical procedures. No transparency how
a category is chosen and rates fixed for that category.
Patient does not know if he has been rightly placed in
the right category for his surgery by hospital. Hospital
arbitrarily decides this higher category to squeeze out
maximum profit not only from patient by exhausting
his mediclaim limits but also from PSU which is
nothing but public money. Hospital refuses to explain
his placement into any such category. Hospital has no
display or catalog or break up for sub rates charged in
any give category. Thus here also GIPSA offers
corruption chance with conspiracy between Hospital,
GIPSA, PSU and TPA. 5. Under what law / rule, 4 PSU
have formed this association ? GIPSA creats monopoly
and is against the earlier policy of creating
complettion in 4 PSU. Like IRDA, should GIPSA also
not get passed by both house of parliament before it
start function arbitrarily. 6. What is Legal identity of
GIPSA. Whether GIPSA is registered under any law of
the land that is whether it is registered as a society or
a trust or under Companies Act. ? In absence of any
such legal identity it is a illegal association to cheat
and commit fraud on public for arbitrarily directing
hospital to charge rates which are many times more
than prevailing market rate charged by that particular
hospital for cash services. 7. In absence of no
governing body that keeps track on the working of
GIPSA makes It venerable to corruption. 8. TPA takes
almost more than 8 to 10 hours to give final settlement
approval for any medical procdure that is needed on
patient to be performed. Due to this delay sometime
the patient misses the surgery on that particular delay
and his fasting during the day for surgery goes
useless. 6 Same 8 to 10 hour time delay is noticed at
the time of final discharge also. Since the patient is
already in hospital for last several days and the TPA
knows his case for last several days still why this
delay in final discharge ?

Read more
at: http://www.lawyersclubindia.com/forum/Gipsa-a-
illegal-association-how-to-get-rid-of-it--68606.asp

I produce herewith news read from Bank of Baroda Staff facebook close group
Posted by Pension Dept. Head Sh. Rajni Jani:

Dear All, I have sent following mails to all

branches.
Dear Sir/Madam

Re: Medical Insurance Scheme for employees-

Benefits of using GIPSA Hospital Packages vs.
Network Hospital vs. Non Network Hospital and
also availing reimbursement route

As you are aware, policy commenced from 1-10-

2015 expired on 30-09-2016 and we have now
obtained the statistics of different types. During
the year, we have come across various issues of
deductions in claims on account of clause
“Customary and Reasonable Charges” etc. In
Banking, this was the first year of Group Insurance
Policy:

On going through the statistics obtained, following

data in respect of hospitalisation claims emerged.
(Amount in Rs.)
EXISTING EMPLOYEES Cashless Claims
Reimbursement
Claims TOTAL
Average Payment per employee Average Payment
per employee
Gipsa Network Hospital 51246 44764 49362
Non Gipsa Network Hospital 64631 80062 67940

RETIRED EMPLOYEES Cashless Claims

Reimbursement
Claims TOTAL
Average Payment per employee Average Payment
per employee
Gipsa Network Hospital 69846 70656 70036
Non Gipsa Network Hospital 87716 92304 88491

Here, it is essential that difference between GIPSA

PPN (Preferred Provider Network) and non GIPSA is
understood. GIPSA stands for General Insurers
Public Sector Association. GIPSA Network
hospitals provides treatment based on rate
schedule separately contracted with all the
insurance companies whereas NON GIPSA Network
hospitals are though network hospitals do not
follow the said rate schedule but are registered as
Network Hospital to provide Cashless Treatment to
Policy Holders.

Above analysis shows that it is always advisable to

prefer GIPSA network hospital as less Insured
amount gets exhausted vis a vis NON GIPSA
Network Hospital. This will help employees to have
more unutilised Insured amount in a year at their
disposal as also it will keep CLAIM RATIO also
under control and will not allow Insurance
Company to raise the premium. Such savings will
help bank to provide more amount towards other
employee welfare benefits.

Therefore, we had requested for GIPSA NETWORK

HOSPITALS list separately from Insurance
Company and the said list is attached for ready
reference. We have also advised the company to
provide such list separately on their website. AS
CAN BE OBSERVED, NO OF SUCH HOSPITALS IS
ALSO MORE THAN 1000 ACROSS INDIA.

This is first of its type communication in the

matter on one observation and some more
observations will follow shortly.

We request you to bring this to the notice of staff

members attached to your branch and retirees
visiting your branch.