As the number of confirmed coronavirus cases in the country spikes, insurance claims for the disease are also on the rise. While the insurance regulator has asked insurers to expedite claims settlement for COVID-19 claims, there have been some instances of the claims being rejected.
If you have faced such a rejection then be rest assured there is still hope.
Sources told Moneycontrol that the Insurance Regulatory and Development Authority of India (IRDAI) will seek detailed clarifications on claim rejections in case policyholders complain.
Insurers who reject claims will be required to explain on what basis the repudiation was done. Unlike other health insurance claims, some special relaxations will be provided for Coronavirus cases.
Customers can contact the Ombudsman in case their COVID-19 claim is rejected terming it as a ‘pandemic’.
Frequently Asked Questions
A vaccine works by mimicking a natural infection. A vaccine not only induces immune response to protect people from any future COVID-19 infection, but also helps quickly build herd immunity to put an end to the pandemic. Herd immunity occurs when a sufficient percentage of a population becomes immune to a disease, making the spread of disease from person to person unlikely. The good news is that SARS-CoV-2 virus has been fairly stable, which increases the viability of a vaccine.
There are broadly four types of vaccine — one, a vaccine based on the whole virus (this could be either inactivated, or an attenuated [weakened] virus vaccine); two, a non-replicating viral vector vaccine that uses a benign virus as vector that carries the antigen of SARS-CoV; three, nucleic-acid vaccines that have genetic material like DNA and RNA of antigens like spike protein given to a person, helping human cells decode genetic material and produce the vaccine; and four, protein subunit vaccine wherein the recombinant proteins of SARS-COV-2 along with an adjuvant (booster) is given as a vaccine.
Vaccine development is a long, complex process. Unlike drugs that are given to people with a diseased, vaccines are given to healthy people and also vulnerable sections such as children, pregnant women and the elderly. So rigorous tests are compulsory. History says that the fastest time it took to develop a vaccine is five years, but it usually takes double or sometimes triple that time.
“Testing and hospitalisation costs could be higher in case a patient is not admitted to a state-run hospital. Quarantine related charges are also high and we are hearing that some insurers are not ready to pay such expenses,” said an official.
As per IRDAI norms, the costs of admissible medical expenses during the course of treatment including the treatment during quarantine period will have to be settled as per policy terms and conditions.
In a regular health claim, the claims settlement officer has a check-list in place. Whatever is part of the list is approved while the rest is rejected.
However, a pre-decided checklist may not work since COVID-19 claims are new to the Indian market. Without past claims data, auto rejections may not be permitted.
Though the government will cover the hospitalisation costs in case a patient is admitted to a state-run hospital, the insured will have to pay for these expenses in case they are admitted to a private hospital and seek tests from private labs.
The insurance regulator has asked the companies to be sensitive to the needs of the policyholders.
While special COVID-19 policies have also been launched, not all of them include travel history. Hence, if someone has been to countries like China, Iran, Italy or Dubai in the past six to eight weeks, there is a high likelihood of claim rejections.
However, considering the severity of COVID-19, insurers could be directed to make basic payouts without large-scale rejections.
The customers also have a higher chance of COVID-19 related claims because IRDAI, as well as the department of financial services, will take re-cognizance of auto-rejected claims.In case an individual has just brought a health product, there would be a waiting period of 30 days for covering any infectious disease.