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Square The Deal, At Ease
Manik Kumar Malakar - 04 June 2021

Filing your insurance claim or seeking reimbursements against your insurance for a medical settlement is a challenge even at the best of times. The pandemic has made this challenging situation a nightmare.

In India’s duel with Covid, the government has put in place a host of guidelines to streamline the entire process of insurance claim settlement, while at the same time thwart any misuse of gaps in the rules.

“If you notice any symptoms that could be related to Covid-19, you should get your test done only at government-approved labs,” cautions Amit Chhabra, Head of Health Insurance at Policybazaar.com.

Covid claims are treated under the general health insurance system. There are two options for making a claim for expenses incurred in the treatment at a hospital. The first is a cashless claim that can only be utilised by the hospitals that have tie-ups with the insurance providers. Do note that the patient has to pay for any treatment that is not included in the health plan.

In case your hospital admission is planned, then do intimate your insurer in advance. If unplanned, you need to inform the insurance company within 24 hours of hospitalisation. For treatment in a non-listed hospital, you should inform your insurer within 48 hours of hospitalisation.

“To ensure that claims are processed fast and smooth, we need to follow some important pre-requisites,” says Amit Sharma, Founder and CEO of eExpedise Healthcare. Important steps in the claims process include intimating insurance company within 24 hours of hospitalisation, submitting all the required documents, including claim reimbursement form, insurance policy, patient ID Card and all the medical documents and reports in original along with the bank account details of the policyholder.

In case of delay or if you do not have anyone to inform your insurer on your behalf, your hospital can do the job. In this process, the settlement might be delayed but the claim cannot be rejected. “Insurance companies can’t deny a claim if a policyholder fails to intimate the insurance companies or third-party administrator (TPAs) within 24 hours of their hospitalisation,” notes Rakesh Goyal, Director of Probus Insurance. This point is relevant if a person is hospitalised alone and needs time for his relatives or friends or colleagues to travel to be with him or her.

It is better to inform insurance companies as soon as possible, but claims will not be rejected on such grounds. Insurers might ask the policyholder regarding claim intimation and they can give them a letter, stating the problem faced by them. “However, they should inform the insurance companies before they get discharged from the hospital,” says Goyal.

Even after submitting all the documents, there may be requirements for additional documents by the claim accessor on additional queries. It is our responsibility to coordinate with the hospital and provide all documents the insurance company demands for the processing and approval of claims. The insurers have made the process of documentation easier by introducing online claim submission facility. It enables faster processing.

The customer has to ensure that they submit complete information in the claim form and all available and necessary documents at one go so that there is no delay due to incomplete documentation. “They should ensure that they submit other information like their bank account details and ID proof at the same time so that unnecessary delay could be averted,” says Shah. The customer can get updated information on the status of the claim on the insurer’s toll free and customer service numbers.

Home treatment is again a cause for concern for most customers when it comes to filing of claims. With more and more people being infected every day, the government is also stressing on treatment at home so long as possible to ease the load on hospitals.

“Almost all insurance companies are trying to settle claims expeditiously but one has to take care of a few things to ensure a seamless claim while taking in-home treatment,” says Pranjal Kamra, Founder and CEO of Finology. If the patient has taken a regular health insurance policy and it has a domiciliary clause, then home care expenses can be claimed if the patient requires to be hospitalised but due to the unavailability of beds, the doctor has advised for home hospitalisation.

The Corona Kavach policy, which is mandated by the insurance regulator Insurance Regulatory and Development Authority of India (Irdai), covers home care expenses for up to 14 days. It covers the cost of the Covid-19 test only if it was done from a government-authorised diagnostic centre.

Apart from signing a claim form and giving the ID proof, the patient has to submit a doctor’s prescription that states that hospitalisation was recommended and a certificate from the doctor for advising home treatment. The patient also has to submit a discharge certificate which would specify the details of the duration of treatment at home.

A daily monitoring chart signed by the doctor should also be submitted. This makes it clear that if the patient is doing self-treatment at home without any doctor’s prescription, then such expenses would not be covered. Also, the patient cannot file a claim if he or she has been home quarantined without any active line of treatment.

“It’s essential for the policyholders to be informed about the cashless claims that they can avail at any network hospitals as well as for insured patients undergoing homecare,” says Anil Pinapala, Founder and CEO of Vivifi India Finance. In such cases, once the medical discharge certificate of the insured patient, signed by the doctor concerned has been submitted, the cashless claim request will be processed.

A circular from the sector regulator has asked the insurers to be more transparent in the claim settlement process, making it convenient for the policyholders to track the status of their cashless claims on an ongoing basis.

In an emergency situation, where an insured patient is forced to be shifted to a non-empanelled hospital where cashless facility cannot be availed, the policyholder has the option of filing for reimbursement of expenses. “You also have the reimbursement process, where you need to pay for the hospital treatment yourself and then you can submit a claim with the insurer to get reimbursed for the treatment expenses at a later date,” says Sunjay Chopra, Co-founder and Director, Money in Minutes.

“In case, there is a denial of cashless treatment at an empanelled hospital, the policyholder must fight for his rights. There is a grievance mechanism and if resolution is not provided, then the grievance can be raised with the insurance ombudsman or Irdai,” says Sanjay Dangi, Director of Authum Investment and Infrastructure Ltd.

When being admitted to the hospital, the patient should bring his or her RT-PCR report, PAN card, Aadhaar card, and medical health card (in Covid-related cases). This helps to speed up claim processing.

According to reports in the media, Covid-related health insurance claims have crossed Rs 23,000 crore for non-life insurers but the average duration of hospitalisation and claim amount have reduced in the second Covid wave compared to the first wave last year. The General Insurance Council (GIC) data reveals that the insurers received 15.32 lakh Covid-related claims till May 20, amounting to Rs 23,715 crore. Out of this, 12.59 crore claims worth Rs 12,133 crore have been settled so far. About 1.13 lakh patients who had filed claims were still under treatment, while 22,461 had died, shows the data. The remaining 13.96 lakh have been discharged.

The average claim size, according to the insurers, has also come down to around Rs 95,000 as against Rs 1,15,000 for Covid patients earlier. The duration of stay has also come down to about six days from the previous nine-day period.


The Insurer’s Eye

We often tend to have negative perceptions about our insurance claim taking time to process. But the fact is that the insurers are swamped with paperwork, due to the unprecedented heavy caseload caused the pandemic.

“Insurers face practical challenges. Several times hospitals are overwhelmed with Covid patients and an insurance company can approve the claim in one hour provided it gets all the documents,” says Nikhil Apte, Chief Product Officer – Product Factory (Health Insurance), Royal Sundaram General Insurance.

“All insurance companies are advised by Irdai to process Covid claims faster based on soft copies, but they still need some basic documents such as admission summary, line of treatment, discharge summary, medicines given and the final bill to process the claim,” says Apte.

It should be noted that the insurance companies too need to beef up their IT systems and processes to comply with the Irdai guidelines on Coronavirus claims reimbursement. While the insurance companies certainly acknowledge the responsibility, they do require some investment in IT and processes, say experts.

Last but not the least, unless hospitals are also equally participating in this initiative, it will be a tough task.

The writer is a financial journalist

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