Insurance & Coverage

Policy, cashless eligibility, pre-authorisation and claims for payer-funded patients.

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Purpose & Business Context

Escrow protects the self-payer; this screen serves the payer-funded patient. It records the insurance policy, checks cashless eligibility, tracks the pre-authorisation / payment guarantee, and follows reimbursement claims — closing the cross-border 'will my insurer pay?' gap that escrow alone does not solve.

Where a guarantee covers only part of the estimate, the remainder routes to escrow self-pay, so the patient always has one clear, funded path to treatment.

Screen Overview

A coverage hero (insurer, masked policy, sum insured, cashless/AYUSH flags), a pre-authorisation tracker that mirrors the visa timeline, and a right column with cashless eligibility, a claims list and a documents link to the wallet.

Controls & Components

• Coverage hero: insurer name, masked policy number, sum insured, cashless vs reimbursement and AYUSH-covered badges, and the split-funding note.
• Pre-authorisation tracker: a stepper from Submitted through Payment guarantee issued to Consumed at admission.
• Cashless eligibility: an eligibility badge and a Re-check action.
• Claims: each claim with id, status and amount.
• Documents: a link to upload claim documents in the wallet.

Field Definitions

• Sum insured: The maximum the policy will pay for the case, in the policy currency.
• Pre-authorisation: The insurer's advance approval; when granted it issues a payment guarantee for a specified amount.
• Payment guarantee: The insurer's commitment to pay the guaranteed amount cashless at the hospital (reference shown when issued).
• Cashless: Treatment paid directly by the insurer at a network hospital, rather than reimbursed later.
• Claim: A request for the insurer to pay or reimburse a specified amount; immutable once submitted.

User Actions & Workflows

1. Confirm your policy and sum insured in the coverage hero.
2. Check cashless eligibility for your treating hospital.
3. Follow the pre-authorisation tracker to the payment guarantee.
4. If the guarantee is partial, fund the remainder via escrow on Payments.
5. After treatment, upload documents and track your claims.

Navigation & Relationships

Reached from the Insurance sidebar item. Couples with Payments (the remainder routes to escrow), the Documents wallet (policy and claim documents), and the clinic's cashless desk on the provider side.

Business Rules & Constraints

• Pre-authorisation requires a verified policy document and a signed treatment estimate.
• The approved guarantee caps the cashless portion; the remainder is self-pay via escrow.
• Claims are immutable once submitted; corrections are made by a new claim.
• AYUSH claims are allowed only when the policy is AYUSH-covered.

Data Dependencies

Reads insurancePolicy, preAuthorization, insuranceClaims and policyInsurer() from lib/data (backed by data/insurance.json). Document links resolve to the wallet.

Error Handling & Edge Cases

• No policy on file shows an empty state advising that most patients self-pay via escrow.
• A rejected pre-authorisation offers guidance and a switch-to-self-pay path.
• A partial approval shows the split-funding explainer with the escrow remainder.

User Roles & Permissions

The patient sees and manages their own coverage. Finance / claims operations act on assigned cases; the clinic's cashless desk reads guarantee status only.

Related Features & Functionalities

Payments & Escrow (split funding), the Documents wallet (policy and claim docs), the clinic cashless desk, and admin insurer empanelment.

Flow & Screenshots

flowchart LR
  Policy[Add policy] --> Elig[Check cashless]
  Elig --> Preauth[Submit pre-auth]
  Preauth --> Guarantee[Payment guarantee]
  Guarantee --> Split[Remainder to escrow]
  Split --> Claim[File claim]

Guided Walkthrough Steps

The in-app walkthrough for this screen has 6 steps (auto-advances every 5 seconds; Prev / Pause / Next; click outside to exit):

1. Insurance & Coverage ([data-tour="nav.insurance"])

For payer-funded patients: record your policy, check cashless eligibility, track pre-authorisation and follow claims.

1. Your coverage at a glance ([data-tour="insurance.hero"])

Insurer, policy, sum insured, and whether treatment is cashless and AYUSH-covered. The note explains any split between guarantee and escrow.

1. Pre-authorisation tracker ([data-tour="insurance.preauth"])

Like the visa timeline: from submission to the insurer's payment guarantee, then consumed at admission.

1. Cashless eligibility ([data-tour="insurance.cashless"])

Confirms your treating hospital is in the insurer's network so treatment can be paid directly.

1. Claims ([data-tour="insurance.claims"])

Track each claim's status and amount. Claims are immutable once submitted; corrections are a new claim.

1. Claim documents ([data-tour="insurance.docs"])

Upload policy and claim documents in your wallet — the same place that drives the visa checklist.