For Planned Hospitalization i. The Insured Person should at least 3 days prior to admission to the Hospital approach the Network Provider for Hospitalization for medical treatment.
ii. The Network Provider will issue the request for authorization letter for Hospitalization in the pre- authorization form prescribed by the IRDA.
iii. The Network Provider shall electronically send the pre-authorization form along with all the relevant details to the 24 (twenty four) hour authorization/cashless department along with contact details of the treating Medical Practitioner and the Insured Person.
iv. Upon receiving the pre-authorization form and all related medical information from the Network Provider, We will verify the eligibility of cover under the Policy.
v. Wherever the information provided in the request is sufficient to ascertain the authorisation We shall issue the authorisation Letter to the Network Provider. Wherever additional information or documents are required We will call for the same from the Network provider and upon satisfactory receipt of last necessary documents the authorisation will be issued. All authorisations will be issued within a period of 4 hours from the receipt of last complete documents.
vi. The Authorisation letter will include details of sanctioned amount, any specific limitation on the claim, any co-pays or deductibles and non-payable items if applicable.
vii. The authorisation letter shall be valid only for a period of 15 days from the date of issuance of authorization. In the event that the cost of Hospitalization exceeds the authorized limit as mentioned in the authorization letter:
i. The Network Provider shall request Us for an enhancement of authorisation limit as described under Section VII.4 (a) including details of the specific circumstances which have led to the need for increase in the previously authorized limit. We will verify the eligibility and evaluate the request for enhancement on the availability of further limits.
ii. We shall accept or decline such additional expenses within 24 (twenty-four) hours of receiving the request for enhancement from You. In the event of a change in the treatment during Hospitalization to the Insured Person, the Network Provider shall obtain a fresh authorization letter from Us in accordance with the process described under VII.4 (a) above. At the time of discharge:
i. the Network Provider may forward a final request for authorization for any residual amount to us along with the discharge summary and the billi...
