The COVID-19 pandemic has created an unprecedented crisis around the world. It is no surprise that individual policyholders and the medical and health insurance sectors face a claim scenario that they do not encounter very often. In some cases, the insurance ecosystem has found a solution, but such scenarios have led to controversy in other cases. See some of them here:
COVID-19 treatment protocols have changed over time, allowing treatment at home for mild cases without co-morbidities, from mandatory hospitalization in the early stages of the first wave. Insurers also began to pay for home remedies and later introduced corona kawach policies ordered by the IRDAI, which included such treatments. The cost of diagnostic tests, doctor's consultation fees, and pharmacy bills are included.
However, the brutal second wave also made it difficult for caregivers to get out of their homes and keep doctors busy. Obtaining physical copies of prescriptions and pharmacy bills is not so easy. Many suggestions and purchase orders are shared in the messaging app. If you have this experience, you should check with your insurance companies on prerequisites when making a claim. “Normal WhatsApp messages do not work. When we receive such claims, we advise policyholders to obtain appropriate prescriptions from hospitals or on a doctor's letterhead. Photographs sent by physicians with such formal prescriptions will also be accepted, ”explained Shankar Bali, Managing Director, Vidal Health Joint, Third Party Organizer.
However, some insurance companies may not insist on such official documents. "We offer home care as a 14-day package as per our policies. We require an electronic proof of RT-PCR positive report and telemedicine services, including regular follow-up." Ordered medications and ongoing blood tests are also covered, "said Star Health & Allied Insurance. Managing Director Dr. S Prakash said.
It was previously pointed out the plight of some people who have been negatively tested but have received COVID-19 treatment based on a therapist's call. Some insurance companies have denied such claims. So, what is the attitude of insurance companies now on this issue?
"Insurers do not insist on a positive RT-PCR. They undergo surrogate tests such as HRCT (CT scan of the chest) and blood reports," Bali said last month, according to the Indian Council of Medical Research (ICMR) with fever, cough, and shortness of breath. Issued guidelines recommending that people suffering be treated as suspected COVID cases.How you can refer to this protocol if your insurance rejects your claim.
When it comes to filing lawsuits, policyholders are hospitalized and face another dilemma under house arrest: taking care of other COVID-affected family members, which delays the claim process. "Although lawsuits were reported in January, we saw many cases filed only in May. As soon as they recover, the priority is, of course, not to file reimbursement claims, but to look after their families. We respect such claims," said Prakash, along with the claim form, medicine, and diagnostics. This also applies to bills. "Most insurance companies are not strict about punctuality.
They realized that policyholders may not be in a position to submit their documents promptly, ”said Dr. Yashendra Sharma, Senior Vice President and Head, Employees Benefits Practice, Alliance Insurance Brokers. If your insurer terminates your claim stating the delay, you can file a complaint first with the insurance company and then with the insurance ombudsman's office. According to IRDAI health insurance regulations, insurance companies should consider such claims when there are valid reasons for the delay. And, the raging epidemic should be counted as one.
Many hospitals have refused to provide cashless facilities to Covid-19 patients, an issue that has caught the attention of Finance Minister Nirmala Sitharaman and the IRDA. Subsequently, following the High Delhi High Court judgment, the insurers were asked to give permission - within 60 minutes - of the cashless authority for admission and at the time of the final discharge. However, the hardships of policyholders are not over yet.
"Hospitals refuse cashless treatment or do not follow the schedule of charges agreed with insurers. Some cite a lack of manpower to complete cashless paperwork. After that, the entire burden falls on the policyholder to pay from his funds," said Sharma. There is very little that a policyholder can do without expending non-existent facilities, so it is advisable to have a large emergency fund capable of meeting 9-12 months' worth of housing expenses. The COVID-19 crisis has only increased the need for this fund.