Saif Ali Khan case: Are celebrities being treated differently by health insurers? Finfluencers highlight problems

Saif Ali Khan's recent health insurance claim, which was leaked on social media, has generated backlash online. The leaked information revealed that Khan had submitted a claim of Rs 35,95,700 for his treatment, despite Niva Bupa initially approving only Rs 25 lakh for cashless treatment.

This incident has shed light on the notable differences in how insurance companies handle claims for celebrities versus the average person, prompting concerns about potential disparities in treatment and privileges for high-profile individuals. Social media platforms are abuzz with comments that celebrities are preferred, while the common man, especially senior citizens, struggle to get their claims settled.

"If any normal person would have gone to Lilavati Hospital, Taken a suite room, Asked for a pre-authorization of 36 Lakhs, And walked out 5 days later... No insurer would have given the claim within minutes, The insurer would have investigated, Raised 1000s of queries, Sent an investigation team 
Scrutinized each report. And Applied Reasonable and Customary Charges to limit the amount of money paid... Just because it has a superstar,The insurer did not want negative PR, His claim was paid within minutes... While the common man struggles to get rightful claims, Insurers treat celebrities in a very different way. IRDAI must step in to make sure, Insurers do not have such disparities, Every common man is a star and deserves to get a high rightful claim, Given that medical emergencies can occur unexpectedly, having health insurance is essential. Familiarising oneself with the claims process beforehand can help prevent last-minute stress," said finfluencer and insurance expert Nikhil Jha.

 

According to Dr. Prashant Mishra, a cardiac surgeon at Tunga Hospital in Malad, Maharashtra, insurance companies often determine the approved amounts for certain treatments, irrespective of the true expenses borne by patients or healthcare facilities.

In a post of X, Dr Mishra wrote: “It's difficult to understand the Health insurance sector. We need to support our senior citizens because most are retired and have no source of earnings or pension. So, Ideally, their Mediclaim premium should be low or fixed. The irony is that Mediclaim premiums for our Senior citizens are very high.”

Last week, an intruder attacked Bollywood actor Saif Ali Khan, leading to a violent confrontation where the actor sustained stab wounds. The intruder was subsequently arrested and the actor was quickly taken to Lilavati Hospital for medical treatment.

Health insurance claim rule change

Patients and their families are often negatively impacted by delays in health insurance claim settlements caused by insurance companies or third-party administrators (TPAs) who work closely with both the insured individual and the hospital.

In May 2024, the Insurance Regulatory and Development Authority of India (IRDAI) recently announced updated regulations for the health insurance industry. According to the new guidelines, insurers are required to provide final authorization within three hours of receiving a discharge request from a hospital.

The regulator stated that in the event of the death of the policyholder during treatment, the insurer will:

i) Immediately process the request for claim settlement
ii) Get the mortal remains (body) released from the hospital immediately

"In no case, the policyholder shall be made to wait to be discharged from the hospital," the regulator said in a master circular dated May 29, 2024. "If there is any delay beyond three hours, the additional amount, if any charged by the hospital, shall be borne by the insurer from the shareholder’s fund."

Additionally, the regulatory body has requested insurance providers to implement a digital pre-authorisation process for policyholders. This process involves the insurer approving a set amount for treatment upfront, with the understanding that the claim will be settled once the final invoice is received from the hospital.

In regards to settling health insurance claims, it has been stipulated that no claims will be denied without the approval of the Primary Medical Consultant (PMC) or the three-member Claims Review Committee (CRC). If a claim is partially denied or repudiated, the claimant will be provided with detailed information referencing the specific terms and conditions outlined in the policy document. 

The regulator said: "No claim will be repudiated without the approval of PMC or a three-member sub-group of PMC called the Claims Review Committee (CRC). In case, the claim is repudiated or disallowed partially, details shall be conveyed to the claimant along with full details giving reference to the specific terms and conditions of the policy document."

Guidelines for claims

IRDAI emphasised the importance of offering a wide variety of insurance products that cater to individuals of all ages, regions, occupations, medical conditions, and healthcare providers. This ensures that customers have the ability to select a policy that aligns with their budget and specific needs.

According to the regulator, policyholders have the flexibility to choose which insurance policy they would like to file a claim under. The insurer of the selected policy will be considered the primary insurer for claim settlement.

Furthermore, policyholders who hold multiple health insurance policies will have the opportunity to decide which policy they prefer to use for settling claims. The primary insurer, to whom the claim is initially filed, is responsible for coordinating and facilitating the settlement of any remaining amount from other insurers, as outlined in the master circular.