The COVID-19 pandemic has unexpectedly transformed the health insurance landscape in more ways than one. Many people who never believed in health insurance are now taking it seriously. Today, health insurance policy sales are skyrocketing as more individuals and businesses are investing in tailor-made health covers as a preparation to combat the COVID-19 pandemic. Insurers are of the view that this new trend may continue post the COVID era too. This is primarily why insurance companies are launching custom policies to cover hospitalisation and treatment costs pertaining to the novel coronavirus. There is also a new trend of opting for home care insurance.
Even after buying a health insurance plan, does an individual get a guaranteed benefit in case of hospitalization or death because of Covid-19? How does one ensure that the Covid policy claims are passed by insurance providers? Here are the answers to your questions on Covid-19 insurance claims and how to ensure that the same are passed.
Basic rules to ensure insurance claim is passed
For most health insurance policies, there are three basic rules to be followed for ensuring that a claim is passed:
1. The hospitalization has to be prescribed by a medical practitioner.
2. Hospitalisation must follow standard treatment guidelines.
3. The active line of treatment should be such that it can only be done in a hospital.
Common reasons for health insurance claims rejection
Lack of documentation
In these tough times, many hospitals are unable to share the required documents and provide the customer’s Covid-positive report to further the claim applications. Insurance providers need to evaluate the criticality of the patient’s condition to understand whether hospitalization was required. Within every claim form, insurers look for detailed bills, discharge summaries, diagnostic reports and prescriptions from doctors. In case of missing documents, the insurers initiate a query. This could either delay the process or stall it completely if documents are not provided as per requirements.
A claim could also get rejected if sufficient reasons for hospitalization are not found as per the protocols set by the insurance provider.
Lack of reason to hospitalize
Hospitalization is not considered essential in case of mild covid symptoms. However, if the patient gets admitted despite having only mild symptoms, the claim settlement for bills submitted may be rejected. Claims may also be rejected for unwanted lab tests and upon submitting bills of outpatient department (OPD) without hospitalization. Even if an individual gets hospitalized, the claim may be rejected in case duration of hospitalization is less than the duration required as per the health policy.
Rejection due to non-disclosure of Pre-Existing diseases
In case the insured has been having a pre-existing disease (PED) for more than a month and it is not disclosed while purchasing a covid-specific health policy, insurers may refuse the claim settlement. Individuals with comorbidities, such as diabetes, blood pressure, etc, must furnish the information related to such diseases at the time of purchase of the policy.
Making claims before waiting period
For covid-specific policies and any other health policies, there is often a waiting period that is required to be completed before making a claim. For covid-specific policies, the initial waiting period is normally 15 days. If a policyholder contracts Covid before purchasing the policy, the disease-specific claim can be made only after completion of the waiting period. If done earlier, the claim may be rejected.
Important Tips to note while submitting Covid insurance policy claims
To ensure that a Covid-19 policy claim is approved, here are some of the important tips to remember while making a claim:
Tests at Government authorised labs
The presence of the novel coronavirus in the respiratory system can be detected through laboratory tests. For this, there are many government-designated as well as private labs approved by the Indian Council of Medical Research (ICMR). The private labs can conduct tests only if prescribed by a qualified physician as per the ICMR norms. Therefore, while filling a claim form, it is important to submit the test report obtained from an authorized laboratory. It must be accompanied by a prescription from a qualified physician recommending the test.
Specify the nature of treatment
With the onset of the second wave of Covid-19 in India, many private hospitals have started offering home care packages for its treatment. If a medical practitioner has recommended this form of treatment for the affected individual, it is important to inquire with the insurer whether such costs will be covered. Generally, a regular, indemnity-based health plan reimburses the hospitalisation expenses and day-care procedures as listed and up to the sum insured within the policy. While making an insurance claim, the insurance provider has to be informed about the nature of treatment sought and whether it is home care, quarantine, or hospital-based treatment.
Furnish pre and post hospitalization documents
Depending on the policy, pre and post hospitalisation expenses may be covered along with ambulance charges and other treatment-related expenses for Covid symptoms. An applicant must ensure that he/she submits all consultation-related documents before hospitalisation and any follow-up treatment post-discharge. It is also important to accompany these documents with bills.
Provide discharge summary where needed
Many people are now buying Covid-specific policy apart from their existing health policies. This allows them to file claims for more than one policy when needed. While making a claim under a benefit policy with higher benefit for ICU admission, it is important to ensure that the discharge summary states the specific number of days spent in the ICU and also a number of days in a standard room. This will help the insurance provider to know the details and accordingly pass the claim.
Ways to avoid health insurance claim rejections
Here are some of the top ways to avoid health insurance claim rejections:
- Ensure that you have read and understood the policy document thoroughly before taking any action. Pay attention to clauses that relate to exclusions and limitations as these can be used to reject claims.
- Ensure that you do not miss premium payments. A lapsed policy is not valid, and any claims made during this period will not be entertained.
- Always provide accurate information while filling out the application form. Any discrepancies may lead to claim rejection.
- Keep all the relevant documents handy, such as your COVID-19 test reports, doctor’s prescription, and hospital bills. This will help in an efficient claims process and avoid any ambiguity.
- Cooperate with your insurer during the claim settlement process. Respond promptly to their requests for information, and provide all the necessary details they need to process your claim.
With these tips you can make your policy claims, whether Covid specific or other health claims, and ensure that the same are passed and settled quickly. The important thing to remember while making any form of health policy claims is to keep the insurance provider in loop at all stages and seek appropriate guidance where needed.