COVID-19: Here’s a primer on getting insurance claims settled on time

Hospital_India

When Abhishek Sinha, a sales executive from Patna tested positive for COVID-19 in March 2021, little did he know that filing an insurance claim would be such a tedious process.

Sinha had made claims for health insurance in the past and knew what documents would be required. What he didn’t know was that the process for getting the claims cleared for COVID-19 would be different.

"We had done a rapid antigen test and then I wanted to get admitted because I was feeling breathless. However, when we reached the hospital and sought cashless treatment, we realised that insurers insist on a RT-PCR report for admission," Sinha said.

His family immediately arranged for testing and only after the positive report was received, was Sinha admitted for cashless treatment.

Amidst the Coronavirus (COVID-19) outbreak, there is also scramble to file medical insurance claims for the hospitalisation treatment as customers have to file reimbursements claims within 15 days. The key to getting the claim settled would be having a list ready of all the documents required.

First, you will need a RT-PCR report that states that you have tested positive for COVID-19. While other ways for testing are available, insurers mandate that hospitalisation claim payment for the virus will only be on the basis of the RT-PCR testing. So do not skip that.

The first thing to do if you have tested positive and need hospitalisation is to have the family check the network hospitals of your insurer. These details will be available in your insurance company website.

Getting admitted into a network hospital is advisable because then your claims can be processed on a cashless basis. However, if there is no bed available in network hospitals, don't fret. Claims can be settled on a reimbursement basis after the discharge.

Second, keep your policy number and insurance card (if any) ready with family members. Hospitals will not be able to assist you in case the health insurance policy has been misplaced. These policy details will be sought for all claims - be it cashless or reimbursement.

Moneycontrol had earlier reported that 171,000 claims are pending approval for settlement.

As of April 28, there were 1.1 million COVID-19 health claims worth Rs 15,568 crore filed with insurers. Of this, 930,729 claims worth Rs 8,918.57 crore have been settled, according to General Insurance Council data shared with the Finance Ministry.

Apart from a tussle between hospitals and insurers on charges, a majority of reimbursement claims are being delayed because of procedural issues. These involve incomplete documents being submitted and a complete breakup of the expenses not being provided.

The third and most critical aspect is to ensure that the hospital provides a proper breakup in the final bill. So, if the medical expenses incurred are Rs 2.5 lakh, the bill has to provide a breakup for all segments, including doctor fee, medical kits, doctor consultation and surgical equipment.

If there is a simple bill with only Rs 2.5 lakh mentioned without detailed breakups, the insurer will not accept this as a valid document.

The insurance regulator and finance ministry are cracking down on delays in claims settlement by insurers. As a policyholder, you/your family could partially help expedite this process by ensuring that the documents are in appropriate order.