Insurers may reject your COVID-19 policy claim - here is why

Patients suffering from the COVID-19 receive treatment inside the emergency ward at Holy Family hospital in New Delhi. (Image: Reuters)

Insurance claims are increasing as the daily coronavirus cases in India are rising. There are several instances when insurers have rejected many COVID-19 policy claims. However, they have accelerated the claim settlement process.

On certain grounds, the insurer can still reject your claims. They may not settle your claim completely when you or your family member get hospitalised.

There are three essential boxes to be ticked for hospitalisation to get covered under health insurance.

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-The hospitalisation must be prescribed by a medical practitioner.

-It should follow standard treatment guidelines.

-There should be an active line of treatment that can only be carried out in a hospital.

COVID-19 health insurance policy claims - Here are the reasons for the rejection of policy claims.

When to Hospitalise?: A patient with severe disease may not get a room or ICU if a person with mild disease is admitted. So, it is important to realise this, given the current situation.

Claim rejection can happen due to unnecessary lab tests, sending bills of the outpatient department (OPD) and asking the insurer to reimburse the claim even without being hospitalised.

Domiciliary Hospitalisation: Claim rejection can also happen when taking domiciliary hospitalisation without prior consent from an insurer.

Waiting Period: The insurer never considers any claim made during the waiting period whether it is a COVID-19-specific policy or any health policy, all of them come with a waiting period.

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Non-disclosure of diseases: Insurers can refuse the COVID-19 claim settlement If the insured has a pre-existing disease (PED) for a month or more and the same is not disclosed while buying a health policy, especially a COVID-19-specific policy.

- Documentation Issue: Sufficient documents are not shared by many hospitals and are sending only the customer’s positive report for insurers to adjudicate the claims.

COVID-19 is usually not covered under day care treatment; it’s either covered under home quarantine, which is payable if covered by the policy, or under inpatient treatment, which is payable if policy terms and conditions are met.

Claims are usually queried due to missing documents. so, proper bills, discharge summaries, diagnostic reports and doctor’s prescriptions should be included with every claim form. As per established protocols, if indications for hospitalisation are not found then the claim may get rejected.

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For COVID-19-specific policies, the initial waiting period is usually 15 days, while for regular health policies, it can go up to 30 days, four years for PEDs, one or two years for specific illnesses, etc.