HR Dilemma: How to Handle a Mediclaim Issue When Hospital Refuses Cashless Payment?

Dear All, I am working as an HR executive and I am the only HR in my company. I handle all HR-related activities, including mediclaim. In mediclaim, usually when there is a claim, the employee should intimate the HR, which is mandatory. One of my employees was admitted to the hospital, so she called me and said that she had some problems and wanted to process through cashless. I did all the necessary work to process with the mediclaim agency, but the next day I heard from one of her friends in the office that the hospital is not cooperating for the cashless process, so she is paying all the bills and wants to reimburse. However, for reimbursement, intimation is also mandatory.

Now, in this situation as an HR, what should I do?
• Call her directly and explain that she can't claim without intimation.
• Leave it as it is and do my work.

I require your valuable feedback in this regard.

Hello Prema, since you work in HR, you are aware that mediclaim insurance is for the benefit of employees, and it is your duty to ensure that your employee who is admitted to the hospital receives it.

From what I can gather from the subject of your email, one needs to set aside ego and simply pick up the phone to guide your friend on how to proceed.

In our company, we have informed all employees about how both the cashless and reimbursement processes work through a formal PowerPoint presentation with the insurance agent. The instructions, toll-free numbers, etc., are displayed in public folders/notice boards. We have made it clear that following the procedures of the insurance company and the follow-up is the employee's responsibility, but HR will facilitate the proceedings and mediate when required or if requested. Sometimes employees do not inform us immediately when lodging claims but only refer to us when claims are refused. However, that's acceptable. There is no question of ego here. It is our job to assist them and hopefully showcase our expertise too.

Regards,
Kalpana Iyer

I have handled mediclaim for my previous company for many years and have dealt with both Cashless and Reimbursement modes of availing the benefit.

Cashless Treatments

Cashless treatments can be availed at the empaneled hospitals when the member of the policy plans for their treatment in advance. The date of admission is pre-fixed by the doctor and intimated to the insurance desk in the hospital. The hospital is supposed to send a "Pre Authorization Form" to the TPA and get the approval for cashless treatment. This is a one/two-day process, and in this case, it is advisable for the employee to inform the employer simultaneously for any cross-checks done by the TPA (Insurance Agents).

Hospitals that are not empaneled will not entertain cashless treatment, and certain hospitals that are empaneled hesitate to process the cashless treatment as the admission is immediate and without advance intimation. In your case, the employee would have faced some problems in obtaining the cashless treatment and, out of urgency, decided to pay from her pocket and claim for reimbursement at a later stage (within the stipulated period specified in the policy).

Reimbursement Process

If the mediclaim facility is availed through reimbursement, there requires no prior intimation. The applicant has to fill in the claim form, add relevant details, obtain authorization from the concerned doctor, attach relevant bills (original), and send it to TPA for payment through cheque.

Kindly go through the policy manual clearly and clarify the clause on reimbursement.

What I Suggest You Do

Call her immediately and describe to her how to go about the same. When you are in HR, shed all your egos and work for the employees' betterment. She may be under a lot of stress and might have missed out on intimating you. So keep your egos apart and talk to her.

- "Leave it and do my work" & "I am working as an HR executive, and I am the only HR in my company. I am handling all the HR-related activities, including mediclaim." If mediclaim is under your purview of work, how can you leave and get back to work?

Regards.

Thank you for your comments, Kalpana and Sriram. Actually, I am not egoistic. The issue here was that, initially, when she needed help with going cashless, she was calling me every half an hour and asking numerous questions. However, the next day, when she faced some problems at the hospital, she did not escalate it to me. Instead, a friend of hers who sits next to me kept informing her. This continuous relay of information irritated me, and I questioned why I should voluntarily offer my help when she was already well-informed about all the mediclaim procedures. Despite her knowledge, she did not reach out to me.

In any case, as Kalpana and Sriram mentioned, we should set aside our egos and assist them. I called her and provided all the necessary information.

Thank you very much.

It is nice to hear from Prema that the need has been addressed. However, my humble suggestion is that a person in distress will yearn for help voluntarily. It will not be fair on our part to stick to rules, hierarchy, etc. at this juncture. Being in HR, let's be a little more magnanimous.

Warm regards,
Venu

Dear Kalpana Iyer,

Do you have any general idea about the Mediclaim rules and regulations in your company? Do you know how to prepare a PowerPoint presentation? Then what restrains you from sharing such a useful article? Remove your company name and logo. Add your comments, and you can give your presentation your own identity with your added remarks. Otherwise, prepare the points and give them in a Word file, which can be helpful to our members.

Thank you.

Dear Prema, please talk to the hospital authorities. Once our staff approaches you, it means you have to provide necessary treatment to them. You should create a format stating that the company will bear the cost of treatment given to them, which will be claimed by the company after submission of necessary documents within 3 days from the date of discharge of the employee or their representative. Any differential amount can be recovered from the employee's salary. Obtain the signature from the employee and get it approved by management.

Then issue a letter to the hospital authorities to treat the employee as per the company standard. The cost will be borne by the company, and make an agreement to that effect with the hospital authority.

Thank you.

1. If possible, a cashless procedure should be initiated one day before hospitalization.

2. Hospitals are not taking risks because of the possibility of insurance companies rejecting claims even after approval for cashless services.

3. The irritation of the employee is evident when looking at the situation in the hospital.

4. Apologizing doesn't mean that you are wrong and the other is right; it only signifies that you value the relationship more than your ego. Bear in mind, if the path is beautiful, let's not ask where it leads. But if the destination is beautiful, let's not ask how the path is.

Regards,
Khedkar Prafulla

Kalpana has rightly said that the detailed procedure to claim the benefits of mediclaim will be given by the insurance company or the broker from where the mediclaim group policy is taken.

Sharing Details About the Mediclaim Procedure

1. Mediclaim policy covers self, spouse, dependent children (max 2), and dependent parents (does not cover in-laws even if the employee is a married woman).

2. Cashless Benefits - Intimation is required to be sent to the HR, and HR in turn will inform the insurance company or broker about the same. There will be two types of Hospitalization:

a) Planned Hospitalization
b) Unplanned Hospitalization

Planned Hospitalization - The required cashless form to be filled in advance should be given to the insurance company or broker. They, in turn, will forward it to the TPA (Third Party Administrator) for approval. Approval will depend upon the kind of hospitalization, limit as mentioned in the policy, etc. An approval shall be received from TPA, and the same should then be produced to the hospital while getting admitted.

Unplanned/Emergency Hospitalization - The employee can take help of HR, and HR can inform the Insurance co/broker about the hospitalization. The Cashless Claim form is available at the network hospitals; the employee will fill the same and proceed as mentioned above.

3. Reimbursements - In case of reimbursements, the employee bears the cost of hospitalization and then gets the same reimbursed by producing the original bills of hospitals, including the admission and discharge card. The employee has to maintain all the bills in original in order to get hassle-free reimbursement. The documents have to be submitted to the TPA/Broker within the stipulated time period as mentioned by them in the policy.

4. Health Cards are given to each and every employee once the policy is taken/renewed. In case an employee loses the card, the same can be availed in a duplicate form from the Insurance Co/Broker.

5. Online facility is also provided by the insurance company wherein HR can have a daily check on the site finding the details of claim registered, the status of claims paid/pending/rejected/in query/etc., and can also get a copy of the Health Card.

Any other queries, please feel free to ask.

Regards,
Smita

Hi Prema, the first step towards sensitive HR is empathy. When she was in need and searching for help, she called you repeatedly. However, once she realized she had to pay, she stopped calling, perhaps to avoid disturbing you further. I am not advocating absolute generosity, but we must develop the endurance to handle various types of behavior, especially erratic behavior under stress.

Secondly, we need to consider whether the formality of informing is a genuine necessity or simply to appease the self-concept of HR personnel. If it is the latter, we should eliminate obstacles and formalities to allow the process to flow naturally. You are the best judge of what transpired between you two. Nevertheless, do not let the mind be distracted by trivial matters and continue working towards the broader goals of HR.

Regards,
ds

Hi Prema, never feel that an employee should always convey everything to you. They may be in a situation where it is not possible for them to communicate with you. As a matter of fact, you could have sent some of your assistants to attend to the patient and keep them comfortable.

Cheer up, get refreshed, and continue your journey towards serving all (Paropakarena idham sareeram).

Okay

Mediclaim Process: Cashless and Reimbursement

Mediclaim is cashless (in the case of an empaneled hospital) or the money spent on the treatment can be reimbursed, as pointed out by Mr. Sriram Warrier. In case of reimbursement, the documents in ORIGINAL need to be submitted to the insurance company. The required documents are:

1. Discharge Summary

2. The bills - including surgery, treatments, post and pre-procedures (like X-Ray, CAT Scan, etc.), medication, etc.

3. The patient's ward reports during the stay in the hospital - such as the visit from the doctor/nurse hourly to the patient during the admission, etc. This report is retained by the hospital - you can obtain a photocopy of this report duly authenticated by the Head of the hospital/Director.

4. The original reports of ECG, Lab Tests, CAT Scan, X-Ray, etc. You can request the insurance company to return these documents for further reference.

5. A clinical report visit to the doctor pre and post-admission - where the doctor prescribes the medicine, change of medicine (if any), etc. Most insurance companies reimburse the cost of the outpatient post-admission charges for 60 days.

6. The claim form.

ALL the above should be authenticated by the hospital. The above is my experience with Medi Calm, and I can say that 90% of the claim was settled within 15 working days. (We have the insurance with Bajaj Allianz where there is no TPA!)

Regards,
Raju Siachen

Based on her information only, you have helped with cashless treatment. Hence, there is no need for separate information for reimbursement. Information may be from either the employee or a colleague; it must be accepted on humanitarian grounds.

Dear Prema,

Medical Attendance and Assistance Policy

Medical attendance and medical assistance (particularly hospitalization) are matters of emergency and distress. It is necessary to know how your company frames such a policy as advance information is required for the same. It is ridiculous. Rather, you should assist the employee in this regard.

However, it is also the duty of the hospital, in the case of a cashless claim, to inform the Mediclaim when the patient declares that they have a Mediclaim cover. But sometimes, in distress, this aspect is ignored or overlooked.

Thank you.

Dear Prerna, don't leave it as such; an employee is an asset to the company. Don't do such acts so that the organization may lose its asset. An appropriate resolution would be to ask the employee to provide an unfit certificate attested by the doctor, mentioning the reason that at that time he/she was not able to inform due to his/her critical stage. It will work anyway as policies are made by humans, not humans made by policy.

Have a great time!!!

Dear Ms. Prema, this is regarding the issue about the systems and procedures, not ego. I would suggest that there is also a communication gap. Please don't expect employees to be 100% perfect when they are facing issues related to medical care as it concerns life and death.

Please support your employees and cooperate with them so that they receive the best support from the company and appropriate treatment. If you support them today, one fine day you will be supported divinely, and the company will also benefit. In any case, neither you nor the company will lose. Please extend your cooperation to the maximum level.

With profound regards

Dear Prema, as an HR professional, you should understand the human psyche and why she is behaving in such a way. Just confront her directly instead of looking for solutions here and there. The solution is within you.

Regards,
Permeshwer Nath

Dear All, Thanks for all your posts, but I will make it clear. This employee initially called me and asked all sorts of doubts. However, the next day, she was calling her friend who sits next to me (in some other department). My question is, if she had a problem on the second day as well, she could have called me instead of her friend. Anyway, her friend cannot provide a solution on medical claims. We have already provided all employees with information on the procedures.

I spoke to her on the same day and sorted out the problem. She is so careless and has not informed either me or her reporting boss about the leave extension.

Thank you.

Dear Mr. S Bhaskar (Boss 2966),

As far as my knowledge and experience go, every company opts for a different type of insurance. For example, my company covers employees, spouses, and two children for "X" amount in staff; the same coverage applies to "Y" amount in managers. However, there is lesser coverage with parents included for workers.

Similarly, every service provider has a different claim settlement process. For example, Star Insurance does not have a Third-Party Administrator (TPA), whereas most nationalized insurance companies have one.

In my experience, when HR wants to formulate and communicate an HR policy to its employees, it is best to be tailor-made and never copied and pasted.

Regards,
Kalpana Iyer

Dear Ms. Kalpana Iyer, I have not discussed the mode or method of the insurance claim, the amount of the insurance claim, or instructed Prema to copy from another company and use the same for her company. I am only requesting Prema to have a helping nature and humbleness when the employees are in need.

Flexibility in Policy Introduction

Whenever we introduce a new policy, there will obviously be some resistance from employees, for which we cannot make it strict from day one onwards. We must be a little flexible and have humane consideration towards needy employees. Otherwise, we cannot maintain employee relationships.

If you feel I have hurt you, please accept my heartfelt apologies.