As India battles the second wave of the COVID-19 outbreak, questions about health insurance coverage for care have naturally risen. Many of these questions are about particular protocols that must be followed in the circumstance when insured individuals look forward to filing a claim with their insurers for the cost of hospitalisation and treatment for Coronavirus.
You already have two choices if you want to make a claim with your health insurer for costs related to COVID-19 care in a hospital, a cashless claim settlement scheme and a claim for medical expenditure reimbursement.
COVID-19 Cashless Claims Settlement Procedure
In the case of a cashless claim, you would not be required to pay for your care because the hospital bill is paid directly by the insurer. Any treatment process or medicines that are mainly excluded from your existing health plan must be paid for by you.
You can only make a cashless claim if you receive care at a network hospital, a hospital that has partnered with the health insurance provider to offer cashless treatment. In an emergency claim, you must notify the insurance provider within 24 hours of being admitted to the hospital. Insured people would prefer cashless claims because these need the least amount of paperwork.
The following documents are needed to submit a cashless claim:
- Existing Health Policy/Insurance Member ID Card (digital or physical copy)
- The insured person receiving treatment’s identity and address proof (Aadhaar, PAN, Driving License, etc.)
- Pre-Authorisation Form (available at the hospital) that is filled up
Step 1. Confirm that the hospital you’ve selected is a member of your insurer’s cashless network.
Step 2. Complete and submit the pre-authorisation form to the hospital who will submit it to the insurer. When the insurer receives the pre-authorisation form, it will be reviewed by health insurance providers. If the specifics and supporting documents are appropriate, the hospital will be approved for cashless treatment service.
Step 3. Receive treatment authorisation from your insurer.
Step 4: The insurance provider will pay the charges covered under health insurance. Before being discharged, pay the hospital for any procedures and treatments that are not covered by insurance.
COVID-19 Reimbursement Claim Settlement Procedure
The reimbursement scheme in health insurance plans allows you to pay for hospital coverage upfront and then make a claim to the insurer for reimbursement at a later point in time. Treatment facilities in several parts of the nation have been overburdened as the COVID-19 crisis has worsened. Consequently, in the event of an emergency, you might be unable to be treated at a network hospital. You may have no choice but to take the reimbursement path in such a scenario.
As part of the claim process, you’ll need to have a few primary supporting documents, such as these:
- Pre-Admission inquiry records
- Test results and reports for treatments performed.
- Cash receipts for prescriptions, medical supplies, oxygen, personal protective equipment, and so on, etc.
- Detailed hospital bills, ICU (Intensive Care Unit), physicians, examinations, etc.
- The hospital’s discharge report
Step 1. Collect all of your COVID-19 treatment hospital bills, invoices, and other documents once the treatment is completed. Carry your exit folder with all of the requisite paperwork once you’ve been discharged.
Step 2. Submit a completed compensation claim, including an original file of the medical records, to the insurance provider.
Step 3. The insured individual will acquire the claim balance within a few days of submitting all required documentation after the entire verification is completed and approval is given.
Step 4. If the insurance provider denies the claim request, you will get a rejection letter that includes the reason for the denial.
For patients receiving home care
Many COVID-19 patients are required to seek care at home, at least before they can access medical facilities, due to a severe shortage of beds in many Indian states. There are various resources available, including online doctor consultations, nurse visits, prescription delivery, and thermometers and oximeters. In addition, some companies provide complete ICU setups at home.
Standard health insurance plans do not cover treatment at home. They only pay for 24-hour hospitalisation and day-care treatments if they include an OPD (out-patient department). Corona Kavach Policy, on the other hand, bears the cost of in-home care. Corona Rakshak Policy also bears the cost of 14 days of in-home treatment.
Corona Kavach Policy
Both general and standalone health insurance companies in India are required by the Insurance Regulatory and Development Authority of India (IRDAI) to provide this policy to their customers. In the current situation when a person tests positive for Covid-19 infection, the policy seeks to cover his/her hospitalisation, pre-and post-hospitalisation expenses, home care recovery costs, and AYUSH treatment.
During the hospitalisation, the policy would also cover any comorbid conditions caused by COVID-19. This policy can be purchased as an entity or a family floater scheme, but it is only available to people aged 18 to 65. The policy, however, would not cover any treatment that is not part of the current pandemic.
Corona Rakshak Policy
IRDAI has released ‘Corona Rakshak,’ a new policy that covers financial risk associated with COVID-19. The new rules require both general and standalone health insurance firms to sell this approach to their customers. This policy is particularly advantageous for those who do not have health insurance. The coverage sum is in multiples of Rs.50,000 and ranges from Rs.50,000 to Rs.2.5 Lac. This policy does not require pre-medical screening.
IRDAI push for faster claims
The Insurance Regulatory and Development Authority of India (IRDAI) has launched specific guidelines for pushing faster COVID-19 health insurance claims. Both general and health insurance providers are required to communicate their cashless approvals to the relevant hospitals and institutions within 60 minutes. In light of the current state of COVID-19 cases in the context of the second wave, and in accordance with the High Court’s orders, IRDAI has given the following instructions to all insurers:
- The network provider (hospital) needs to be informed about authorisation for cashless treatment procedure for COVID-19 claims quickly in 60 minutes of obtaining the authorisation application and all required hospital specifications.
- Within an hour of receiving the final bill and all relevant conditions from the hospital, a decision on the final discharge of patients covered by COVID-19 claims must be conveyed to the network provider.
Having insurance during such a crisis is essential for avoiding the financial strain that can accompany coronavirus treatment. Assess the requirements before making a decision. Also, be familiar with the benefits of your health insurance policy’s coverage so that you can make an informed decision on filing a claim for coronavirus.
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