COVID-19: Policyholders get only 45-80% of bills

As the number of people hospitalised due to COVID-19 rise, many find that they have to settle a big chunk of the bill out of their own pockets despite having health insurance. Policyholders are again caught in the crossfire between hospitals and insurers over the treatment of consumables like personal protection equipment (PPE) kits resulting in only 45% to 80% of hospital bills being recoverable by customers.

For 81-year-old diabetic and hip fracture patient K Saraswathi, who was treated for COVID-19 for eight days got only Rs. 56,500 reimbursed of the total Rs. 1.18 lakh bill from third-party administrator Raksha. Among other things that were disallowed included Rs. 17,600 for PPE claims. While insurers cite General Insurance Council (GIC) norms their argument may not hold water as IRDAI has not approved any norms.

“How can a hospital treat a patient without PPEs?” asked an official at the Insurance Ombudsman office which is snowed under with complaints for short-settlement. “We used to get a few cases last year, now we have 88 pending cases, 70% to 80% of which are short settlements,” the official added.

For some insurers, the exclusions amount to a third of hospital bills. Liberty General officials said that around 35% of the bill does not fall under the ambit of insurance coverage.

Amol Sawai, VP and national claims manager for accident & health, Liberty General, said, “On the industry level, the average COVID claim severity is Rs. 1,40,000, the settlement severity is about Rs. 95,000 of the claimed amount. We have seen almost 20% of the total bill is attributed to PPE costs.”

India’s largest health insurer Star Health settles nearly 80% to 90% of claims under cashless settlement within two hours of receiving claims.

S Prakash, MD, Star Health, stated, “One doctor who takes a round in the same PPE kit, cannot charge for each of ten patients he visits. The controversy is not in the reimbursement for PPEs, but in the number of PPEs covered. One cannot claim for ten PPEs per day. For ICUs, we allow a higher number of PPE kits compared to the ward.”