You buy a health insurance policy to protect yourself against sudden hospitalisation. The cashless claim ensures all medical expenses are taken care of by the insurance company since the beginning and you don't have to spend a penny (except a nominal amount) in the hospital. However, these are exceptional times.
The insurance companies are swamped with COVID-19 claims. Even if your policy is eligible for cashless settlement, the insurance companies are not offering it. You will have to pay the full amount yourself and file the reimbursement later. Even Finance Minister Nirmala Sitharaman has taken cognisance of it. She has spoken to IRDAI chief to look into the matter.
Besides, in some cases, the private hospitals are charging much higher prices than what the government has prescribed and the insurance companies are refusing to pay those.
When Ghaziabad-based Tushar Agarwal, General Manager IT and Operations at Caritas Eco Systems, got hospitalised due to Covid, the hospital charged Rs 4,200 per vial for anti-viral drug Remdesivir. "The insurance company only paid around Rs 2,300 saying this is the limit that the government has specified," says Agarwal.
Similarly, the full amount for PPE kits is not being reimbursed. In case of room rent, Agarwal says his policy has a single occupancy room limit of Rs 15,000. However, due to lack of availability of single rooms, he stayed in a twin sharing room. "The hospital gave me two bills. One nearly of Rs 1,50,000 having general ward charges and other medical expenses. They charged additional Rs 8,000 per day room rent separately in a Rs 50,000 bill. The insurance company only entertained the first bill," he says.
Why was Tushar slapped with two bills? "The UP government had capped Rs 8,000 rent limit per day for isolation beds. So even though I was in double sharing, they only showed Rs 8,000 in regular bill to meet government cap while rest of the rent was charged in a separate bill. Who would have time and effort to fight this mess?"
Agarwal still wrote several mails to insurance company against such discrepancies and received an additional Rs 10,000 claim.
Further, the insurance companies are only honouring RT-PCR tests, not rapid-antigen, in claims settlement. There is another catch. "If your test report lacks SRF (specific reference number), which most of reports from private labs would, the insurance company may not settle the amount," says Shailesh Kumar, Insurance Head & Co-Founder, Insurance Samadhan.
In some cases, insurance companies are rejecting the claim saying the policyholder did not need hospitalisation based on the CT value of the Covid test. "Who will decide whether someone needs a hospitalisation or not? CT value is not a correct way to judge the severity of the infection. Many doctors have made it quite clear," says Kumar.
Indraneel Chatterjee, Co-founder, RenewBuy says in many cases it has been observed that people rushed to the hospital even if Covid symptoms were mild just because they were insured. He advises people to opt for home treatment. "Insurers honour home treatment for Covid. Rather than rushing to the hospital, if symptoms are not severe you can get treated at home. The hospitals are offering Covid packages which are covered by insurers."
IRDA has a guideline that says a public insurance company will pay Rs 10,000 per day for all Covid-linked treatment, Rs 15,000 per day when the patient is in ICU and Rs 18,000 per day when he or she is on ventilator support. "But these are the limits for public insurance companies. Private insurers are also limiting the claims to these levels, which is wrong."
In another instance, the insurance company didn't pay for co-morbidity. "The insurance company refused to pay the treatment for an existing disease that needed care along with the Covid treatment. Who else will cure the other disease? The hospital itself no! Why should it get excluded out of insurance?" says Chatterjee.
Avdesh Mishra, CEO, Caterpillar Insurance & Investments has two practical suggestions for those getting hospitalised. "People tend to take up deluxe suite if their policy has no room rent limit. What they don't understand is the doctor consultation charges and other facilities are charged at higher slab in such rooms compared to single AC or other normal rooms. The insured will exhaust their policy coverage soon."
Most insurance policies cover 30 days pre-hospitalisation and 60 days post-hospitalisation expenses. "But if your medicine or lab bills don't have a 'paid' stamp, the insurers might reject it unless you produce it with the stamps. Patients need to keep OPD and other such bills safe," he says.
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