Like lakhs of Mumbaiites, 51-year-old entrepreneur Sukesh Jain (name changed) tested positive for COVID-19 earlier this month, as did his wife and daughter. While the latter two recovered at home, Jain decided to get admitted to a hospital as he is a diabetic. He was discharged after three days, but his health insurance company rejected his cashless claim on the grounds that his condition did not warrant hospitalization.
“He had mild fever and cough, but also co-morbid conditions. Jain was admitted to the hospital after the attending doctors evaluated his case. He was also administered Remdesivir (which is possible only in a hospital setting). Yet, his insurance company rejected his cashless claim,” says his financial advisor who spoke to Moneycontrol on the condition of anonymity as the grievance redressal process is still in progress.
Treatment of mild COVID-19 cases
Last year, Moneycontrol had highlighted cases where insurance companies had rejected COVID claims on the grounds that hospitalization was unwarranted. Some of these claims were settled after the aggrieved policyholders knocked on the insurance ombudsman’s doors. “It’s not the insurer, but doctors and hospitals who have to take these calls. The patient is not in a position to decide whether hospitalization is needed or not. Given a choice, they would prefer treatment at home. Insurance companies should give them the benefit of doubt. We have observed that generally, the corporate group health claim settlement is smoother than retail policy claim processing,” says Rishabh Parakh, Founder of NRP Capitals, a financial planning firm.
Such cases could come to the fore once again in this Omicron-driven wave, with most individuals experiencing mild symptoms. The Indian Council of Medical Research’s (ICMR’s) latest COVID-19 treatment protocol categorizes those with fever and upper respiratory tract symptoms, but no shortness of breath or low oxygen levels as mild cases. Home treatment is recommended for such COVID-positive patients. “Initial data suggests that the number of hospitalization claims that we have received so far is lower as compared to the second wave. Most patients are recovering at home. Some, however, have panicked and rushed to the hospitals. We are concerned, but have not denied claims,” says Atul Sahai, Chairman, and Managing Director, New India Assurance, India’s largest general insurance company.
No claim settlement for mild COVID-19 cases?
He says the company’s decision is guided by the treating doctors’ views and ICMR treatment protocols. “Largely, the vulnerable groups – elderly, people with co-morbidities, and those who are not fully vaccinated seem to be more impacted and need hospitalization. Ultimately, it’s the hospitals that are making the calls on admission. We understand that many hospitals are generally not admitting COVID patients with mild symptoms,” he adds.
Insurers say they rely on guidelines issued by ICMR. “In the case of COVID-19 treatment, the ICMR-prescribed protocol is clear on when a patient should be treated at home, admitted to hospital, moved to the oxygenated bed, or shifted to ICU. As insurers, we follow the laid-out protocol. In a pandemic, a huge number of cases can overwhelm the medical infrastructure. If patients who can be treated at home are admitted, patients who need hospitalization will be deprived of the beds. So, in cases where patients with very mild disease and did not need hospitalization were erroneously admitted, we could unfortunately not pay the claims,” explains Dr. Bhabatosh Mishra, Director, Underwriting, Products and Claims, Niva Bupa Health Insurance.
Sure enough, insurance broking and claim management firms have seen some insurers rejecting ‘mild’ COVID hospitalization cases. “One of the reasons for claim rejection is that some patients get admitted to hospitals anticipating that their condition could turn serious later. In such cases, we have seen that if the condition is not serious at the time of admission and stays that way, some insurers reject the claim,” says Anuj Jindal, Founder, Sureclaim.in. In one such case that Jindal came across, the hospitalization claim of an individual who landed in India recently and tested positive with mild symptoms was rejected. “The situation at that point in time forced him to get admitted to a hospital even though he had mild COVID-19. The insurance company rejected his claim,” he adds.
Patient-policyholders may face claim rejection if the insurer’s scrutiny of their condition does not tally with that of the hospitals. “The team of doctors at the insurer’s end go through the clinical documents of the customers and on the basis of vital parameters and doctors’ recommendation, determine whether the hospitalization is required,” explains Kulin Shah, Co-founder, and COO, Onsurity, a health-tech firm that also facilitates group health covers through tie-ups with insurance companies.
Recourse for policyholders
Even if your claim is rejected by the health insurer, you need not accept it as the final verdict in case you feel your hospitalization was justified. The first stop is always your insurance company’s grievance redressal cell. If the escalation fails to elicit a satisfactory response or any response at all, you should approach the insurance ombudsman office in your city. The last resort for all such cases is the consumer courts.