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Mediclaim Intimation Letter Format: How to write health insurance intimation letter?

By Spider Computech on
Mediclaim health insurance symbol logoTo avail benefits of health insurance, intimation letter to the TPA must be furnished within 24 hours of admitting the patient to a hospital or nursing home. At worst cases, insurance companies may reject your claim if you fail to do so. Of late, a court declared that attending a critical patient is more important than furnishing the hospitalization intimation letter for mediclaim, but who wants to have legal troubles? Intimating the TPA within a day of hospitalization if possible is the best practice.

If you are in a hurry to write a mediclaim intimation letter or email yourself, or if you have no idea how to write an intimation letter to health insurance TPA for planned or emergency hospitalization, we may help. Use or bookmark this model mediclaim intimation letter to quickly edit and insert the necessary details about your patient and insurance policies, and you are done! So, here we go.


What is a TPA? Why do they need mediclaim hospitalization intimation letter?


TPA is an abbreviation or short name of Third Party Administrator. The insurance company outsources the TPA to handle their processing jobs and settles your claims. The Wikipedia defines TPA as an organization that processes insurance claims or certain aspects of employee benefit plans for a separate entity. On the other hand, to intimate is to to inform. When you write an intimation letter to health insurance TPA, you simply let them know in due time that a certain patient has been admitted to a healthcare institution, and you are going to claim cashless facilities or reimbursements for incurred expenses shortly. This helps the TPA prepare their documents for settling the claim with the insurance company on your behalf.


When to write an intimation letter to mediclaim TPA?


It is recommended that both for emergency hospitalizations, you should inform the TPA within 24 hours, though the timeframe may be 48 hours for some companies. For planned hospitalizations, the TPA should be informed 48/24 hours prior to the hospitalization. Many TPAs may have specific forms for this purpose, and this may vary from one TPA to another. Therefore, you should first consult either your health insurance provider or the third party administrator regarding any intimation form(s) that they might already have. The hard-copy of the form may be supplied to you or you may be asked to download it from the respective website. You might also be required to fill and submit the mediclaim intimation form online, if need be. Some TPAs are also allowing hassle-free intimation by phone or SMS these days.

An intimation letter, on plain paper or by email, is required only if there is no such form available. The letter may be computer-typed or hand-written.


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What to write in a health insurance claim intimation letter?


Your mediclaim intimation letter to TPA should typically contain the following information for the perusal of the insurance company:
  • The name of the patent, diagnosed illness, treating doctor, medical institution where the treatment is to take place
  • Your health insurance policy number, mediclaim health card number, TPA registration number and similar details
  • Preferably, you should attach scanned copy of all necessary documents like the prescription of your doctor advising hospitalization, insurance policy, health card etc.


Sample mediclaim intimation letter for hospitalization for health insured patients


To
M/s ABC TPA Pvt Ltd
[Full postal address of the TPA]

Sub: Intimation for hospitalization of [NAME OF THE PATIENT] for [NAME OF THE DISEASE] at [NAME OF HOSPITAL / NURSING HOME]
Re: Mediclaim Policy Number xxxxxxxxxxxxxxxxxxxx and TPA Health Card Number xxxxxxxxxxxxxxxxxx

Sir / Madam,

This is to intimate you that my father / mother / husband / wife [or whatever relation with the claimant], Mr./Ms./Mrs. [NAME OF THE PATIENT] has been admitted to [FULL NAME OF THE HOSPITAL / NURSING HOME / OTHER MEDICAL INSTITUTION] for treatment / surgery of [NAME OF THE DISEASE] under [NAME OF THE DOCTOR(S)]. The surgery will be done on [date: xx/xx/xxxx].

May I please request you to intimate the insurance company so my claim may be settled in due time? I am attaching herewith the scanned copy of the medical advice regarding hospitalization, our health insurance policy, and the health card.

Looking forward to your kind cooperation,

Thanking you,

Yours sincerely,

[YOUR NAME]
[YOUR FULL POSTAL ADDRESS]
[YOUR CONTACT NUMBER]



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What if you fail to intimate the mediclaim TPA about hospitalization?


If you have carefully gone through your health insurance policy, you might have noticed conditions like failure to intimate TPA as soon as the claims occur may invalidate your claim. Typically, if you do not intimate the TPA on time, the insurance company may reject your claim on that ground.

However, the South Mumbai District Consumer Forum in the case of Consumer Welfare Association & Anr v/s United India Insurance Co & An recently held that the insurance companies cannot reject claim simply on the basis of failure to intimate the TPA when saving and taking care of the patient assumes priority. A Times of India Report said:

There are times when a medical emergency may arise, where the priority is to get the patient admitted and treated, rather than waste time in digging out the policy to send an intimation about the hospitalization. In such a case, the insurance company attempts to capitalize on the non-intimation by rejecting the claim.

While this is certainly a welcome news for the insured claimant (as there have been several cases of claim rejection citing non-intimation as the reason), please note that writing intimation letter to mediclaim TPA about hospitalization is still the standard practice. Many TPAs may still reject your claim or harass you for failure of intimation. If there is an emergency and you simply cannot find time to post the letter, and the claim is rejected subsequently, you should take up the case to courts. Apart from that, whenever possible, an intimation is the advised way.



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