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Admitted to a hospital with mild COVID symptoms? Your insurance claim may be rejected

One of the reasons for claim rejection is that some patients get admitted to hospitals anticipating that their condition could turn serious later

January 19, 2022 / 09:54 AM IST
Representative image

Representative image

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 hospitalisation.

“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.

Also read: Insurers see spike in Omicron claims, but fewer than in second wave  

Treatment of mild COVID-19 cases

Last year, Moneycontrol had highlighted cases where insurance companies had rejected COVID claims on the grounds that hospitalisation was unwarranted. Some of these claims were settled after the aggrieved policyholders knocked on 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 decide whether hospitalisation 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.

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COVID-19 Vaccine

Frequently Asked Questions

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How does a vaccine work?

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.

How many types of vaccines are there?

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.

What does it take to develop a vaccine of this kind?

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.

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Also read: Health insurance claim settlement hinges on IRDAI nudge   

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 categorises 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 hospitalisation 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 hospitalisation. Ultimately, it’s the hospitals that are taking 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 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 hospitalisation will be deprived of the beds. So, in cases where patients with very mild disease and did not need hospitalisation 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 hospitalisation 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, hospitalisation 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 hospitalisation 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 hospitalisation 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 are the consumer courts.



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Preeti Kulkarni is a financial journalist with over 13 years of experience. Based in Mumbai, she covers the personal finance beat for Moneycontrol. She focusses primarily on insurance, banking, taxation and financial planning
first published: Jan 19, 2022 09:54 am
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