Didn’t Get A Hospital Bed For Covid-19 Care? Won’t Be Easy To Get Insurance
Health Insurers use discretion to settle claims for Covid care treatment taken at home.
In late October, Dipti Avlani, 51, felt fatigued without exertion and started losing her sense of smell. As feared, she tested positive for Covid-19, and continued to have a high-grade fever and shortness of breath. Her CT scan and blood reports indicated an infection level "above minor". As hardly any beds were available in pandemic-designated hospitals in Mumbai then, her family said, she availed treatment at home.
Avlani consulted her family doctor, a general practitioner, and a lung specialist, who prescribed medication and advised her to track vitals at home. After she recovered, her insurance adviser Ankit Mehta filed a claim for treatment expenses along with all supporting receipts for Rs 19,338 on Dec. 3.
HDFC Ergo General Insurance Co., however, rejected, the claim citing that her infection was mild and didn't require hospitalisation. In an emailed response to her, the insurer said the documents suggested she was advised home isolation and oral medication. The claim can be paid out only if "the insured was admitted as in-patient and the treatment would have required minimum 24 hours of hospitalisation or treatment was a part of enlisted daycare procedures identified by the insurer", it said.
The company declined to comment on BloombergQuint’s queries.
Avlani’s case underscores how there’s a lack of clarity on insurance claim payouts during an unprecedented situation such as the pandemic. Usually, hospitalisation is a must to settle regular claims unless buyers have an add-on for home care. But finding a hospital bed during Covid-19 is not certain as the nation’s healthcare system is overwhelmed by extremely critical cases. Insurers are using their own discretion to settle such claims.
Mehta cited another example. He filed a claim on behalf of another client who also recovered from Covid-19 at home. The policyholder didn’t want to be identified—BloombergQuint reviewed claim documents.
Against a demand of Rs 39,523, spent on RT-PCR tests, blood tests, CT Scan, doctor consultation charges, medicines, United India Insurance paid Rs 15,000 citing a sub-limit in the policy for treatment availed at home.
To be sure, the insurance regulator has asked insurers to promptly settle claims related to the pandemic, besides offering standardised Covid-19 cover. The Insurance Regulatory and Development Authority, however, issued no specific directions regarding domiciliary hospitalisation claims.
S Prakash, managing director at Star Health and Allied Insurance Co., said most of their policies have the domiciliary hospitalisation clause and "a treating doctor’s written diagnosis and necessary scans or blood reports makes one eligible to claim reimbursements under this clause." But within a sub-limit.
ICICI Lombard General Insurance Co. also has a similar domiciliary hospitalisation clause, Sanjay Datta, chief- underwriting, claims and reinsurance, told BloombergQuint. Under most of its policies, the insurer “also offers cashless treatment provided at home via network hospitals”, he said.
Insurers are within their right to reject claims above the sub-limits as companies can't be expected to bear the brunt of an unusual situation, according to Anuraag Sundar, an insurance analyst. “As a humanitarian gesture, the government may step up and make good of the amounts over and above the prescribed domiciliary hospitalisation limits set by private companies."
The assertion, however, disregards the problem that hospital beds are not easily available even if one were to seek admission. Like in Avlani's case.