The most optimistic hearts have been broken by the second wave, and the stoic are shaken.
Society struggles to get out of the pit rushing to the aid of a neighbour, stranger or a loved one to procure oxygen, medication or a hospital bed. Battles are waged every day. Won or lost, at the end of it are the bills.
What is the situation if one has to make a COVID-19 health insurance claim?
If you have a hospitalisation policy, it will pay for your COVID-19 treatment as per policy terms. The disappointment is that many non-medical expenses, like PPE kits and sanitisation costs, that characterise COVID treatment protocol are not payable.
However, the Insurance Regulatory and Development Authority of India has announced that treatment at home, provided it is on a doctor’s recommendation, is covered, as also treatment at makeshift or temporary hospitals, including hotels with COVID-care facilities, which have come up in response to the surge in cases. These are pandemic-specific measures and they don’t apply to isolation which is a precaution, not a treatment.
Cashless treatment
Coming to cashless treatment, yes, you are entitled to cashless treatment at network hospitals, as usual, including at makeshift or temporary hospitals put up by the network hospital. Another pandemic instruction to insurers has been that they should sanction cashless claim requests within 60 minutes.
You should hold your insurer and TPA to these norms. If you find resistance, please send a written complaint to the grievance officer of your insurance company — their contact information and instructions are available on the IRDAI website (www.irdai.gov.in) under the link ‘Grievances’.
You can escalate the complaint through IRDAI’s call centre and the Integrated Grievances Management System, both of which are available in the same ‘Grievances’ section.
If treatment is at a non-network hospital, you should pay your hospital bills and seek reimbursement from the insurer by going through the claims process.
Claims for treatment costs at such facilities follow the same norms depending on whether they are put up by a network or a non-network hospital.
A network hospital means one that is empanelled by your insurance company and is part of its Preferred Provider Network which is usually countrywide. Insurers have arrived at pricing matrices for treatments at these hospitals and have put in place systems for documentation and payments.
Your insurer will provide you with a list of the network hospitals along with your policy. Or you can get it from your agent, the company’s website or your Third-Party Administrator (Health Services) or TPA.
Inform your TPA
The TPA is an important link in your claims process. It is to the TPA you first intimate your impending hospitalisation. In case of emergency hospitalisations, you can inform them at the earliest with the policy details and other information they need. Usually, your health insurance identity card will suffice to start the process. The smart thing to do is to ensure it is handy and keep a scanned copy of it on your phone.
Document check
Ensure you have all relevant documents such as doctors’ prescriptions and every document and bill from the hospital including the discharge summary, payment receipts, medicine bills – ensure the patient’s name appears on each bill, it’s easy to forget amid anxiety – test requisitions, results, bills and receipts, bills for consumables like PPE kits, gloves and masks. This applies especially if you are not going the cashless route. And in the melee, don’t forget to renew your health insurance policy.
COVID-19 treatment at government facilities is free and some States have started announcing free treatment at private hospitals also, for beneficiaries of mass insurance programmes.
If you know any such case where somebody has succumbed to the virus, you can advise the family to make a life insurance claim under schemes such as the Jeevan Jyoti Bima Yojana, which has a sum assured of ₹2 lakh with an automatic premium debit of ₹330 through the linked bank account — usually the Jan Dhan Account on June 1 every year.
Similarly remind them to claim under any employer schemes and EPFO Group insurance schemes as also group policies under their bank accounts, credit cards or even mobile phone connections.
With entire families facing financial devastation, every little bit helps.
(The writer is a business journalist specialising in insurance & corporate history)
Please Email the Editor