Mumbai: Hospitalizations in the middle of the coronavirus pandemic, even if a patient has not contracted the virus, may add thousands of rupees in out-of-pocket expenses as insurers are unwilling to cover the costs of personal protective gear as they fall in the list of non-payable items.
Patients could end up spending as much as a fourth of their hospital bills on personal protective equipment (PPE) during an extended hospitalization, according to some experts.
The highly contagious nature of the virus and the severity of the outbreak has forced hospitals to make it mandatory for health workers to wear protective gear, including body suits and face shields, adding to the costs of patients, as well as hospitals.
What’s making matters complicated is that costs of PPE kits are not standard. Given the varying and unregulated costs of PPE kits, many insurers are wary of hospitals overcharging them.
Mahavir Chopra, a health insurance expert, said he has seen hospitals levying special charges for care and hygiene to manage covid-19 patients. “These charges include cost of PPE billed at as high as ₹5,000-9,000 a day; care and hygiene, and waste management charges, which are otherwise part of the room rates," Chopra said. “The current construct of a health insurance policy does not cover these specialized charges for covid treatment, including the cost of care and hygiene and, hence, insurers are not wrong in making such deductions," he said.
The Insurance Regulatory and Development Authority of India (Irdai), in its circular dated 27 September 2019, published a list of 68 items that can be treated as optional. The list includes kits that are used for treatment of patients. The regulator has left it to the insurers’ discretion whether they want to pay for such kits.
“Such costs are not covered as they can be treated as optional. The regulator has mentioned ‘kits’ in the list because there are a variety of them available and PPE is just one of them," said Prasun Sikdar, managing director of ManipalCigna Health Insurance Co. Ltd.
The excluded items, which also include oxygen masks, may account for almost 20-25% of hospital bills. Given that the average cost of covid-19 treatment could be ₹1.9 lakh, a patient may have to pay as much as ₹47,500, or 25% of the hospital bill.
This is not a blanket exclusion and insurers are paying for kits wherever it forms a part of the packaged rate. “If PPE kits get billed into the overall room charges, insurers pay for it, but if they are shown separately like in the case of non-covid treatments, then they can be excluded," said Kapil Mehta, co-founder, SecureNow.
Anything that is billed exorbitantly will not be covered, said Dr S. Prakash, managing director of Star Health and Allied Insurance Co. Ltd. “Exorbitant by definition means anything that is above the market price. There are various grades of PPEs. Hospitals can charge up to ₹1,000," said Prakash.
Insurers said there’s a problem with the number of kits that are billed as well. Dr Prakash said if there are 10 patients in an ICU and there are four nurses in four shifts, 16 PPEs are used in a day to take care of 10 patients. So each patient should be charged for 1.6 PPEs per day. “If every patient is charged for four PPEs for four shifts, it is exorbitant. If we find such abnormal instances, we won’t cover."
Insurers paying for PPE kits don’t seem to be picking the tabs for non-covid patients. For instance, New India Assurance, Oriental Insurance, National Insurance and United India Insurance are covering the cost of PPEs for covid patients if it is under reasonable and customary charges, said Dr Suman Tilak, chief medical officer, Paramount Health Services (TPA) Pvt. Ltd. Only New India Assurance has agreed to cover PPE costs for non-covid patients, she added.