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Home >Money >Personal Finance >Here are the reasons why insurers may reject your covid policy claim

As the number of covid cases rise, insurance claims are also increasing. Although insurers have expedited the claim settlement on covid-19, some cases were also rejected.

When you get hospitalized, the insurer can either reject your claims on certain grounds or not settle your claim completely.

Technically, a hospitalization has to tick three essential boxes for it to be covered under health insurance. First, the hospitalization must be prescribed by a medical practitioner. Second, it should follow standard treatment guidelines, and most importantly, there should be an active line of treatment that can only be carried out in a hospital.

“For instance, if you have mild covid symptoms, only on oral tablets, no other treatment, monitoring is required while you are in hospital, then this treatment in the hospital won’t be covered under health insurance," said Mahavir Chopra, founder and CEO, Beshak.org, an independent consumer awareness platform for individual insurance buyers.

There are multiple reasons related to the rejection of covid health insurance policy claims.

DOCUMENTATION ISSUE

Insurers are observing that many hospitals are not able to share sufficient documents and are sending only the customer’s positive report for insurers to adjudicate the claims. This is leading to more queries.

“As an insurance provider, we need to evaluate the severity of the patient’s condition to know whether he/she met the hospital admission criteria or not. We do refer to AIIMS, government, WHO and ICMR guidelines on severity classification and to judge the need for hospital admission vis-à-vis home quarantine," said Bhabatosh Mishra, director - products, underwriting and claims, Max Bupa Health Insurance.

Covid is usually not covered under daycare 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.

Every claim form should include proper bills, discharge summaries, diagnostic reports and doctor’s prescriptions. Claims are usually queried due to missing documents.

Moreover, a claim may also get rejected if indications for hospitalization are not found as per established protocols.

WHEN TOHOSPITALIZE?

Given the current situation, it is extremely important to realize that if a person with mild disease is admitted, a patient with severe disease may not get a room or ICU.

“Hospitalization is not required in case of mild covid symptoms, but if the patient still gets admitted, and the bill is raised, claim settlement can get cancelled in this case too," said Indraneel Chatterjee, co-founder, RenewBuy Insurance.

Unnecessary lab tests, sending bills of the outpatient department (OPD) and asking the insurer to reimburse the claim even without being hospitalized can lead to claim settlement rejection.

“We are also witnessing incidences of unnecessary tests and usage of higher antibiotics like Meropenem and Targocid in the current wave. This has led to an increase in the overall size of the claims," said Mishra.

According to Abhijit Chatterjee, executive director, IFFCO Tokio General Insurance, even if you get hospitalized, the claim is not considered if the duration of hospitalization is less than the duration specified under the health policy.

NON-DISCLOSUREOF DISEASES

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-specific policy, insurers can refuse the covid claim settlement.

“Claims from several health policies where policies have been obtained fraudulently by not disclosing PED are rejected," said Sanjay Datta, chief - underwriting, claims and reinsurance, ICICI Lombard General Insurance.

“Insurers will review the clinical parameters that are in line with industry practices as insurers also use doctors for the same. Once the clinical review is done and the line of treatment is reviewed, claims are approved," he added.

Indraneel Chatterjee added, “If the insured has co-morbidities like diabetes and/or blood pressure, and he or she does not furnish the information correctly at the time of purchase, the claim can get rejected. Insurers usually can find out these discrepancies sooner or later."

WAITING PERIOD

Whether it is a covid-specific policy or any health policy, all of them come with a waiting period. The insurer never considers any claim made during the waiting period.

For covid-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.

If a policyholder has covid before buying the policy, the claim for treating the disease can be made after the waiting period is over. “Covid claims also have an initial waiting period from the start of the policy; if the claim is applied in the initial waiting period, it will be rejected," said Dutta.

DOMICILIARYHOSPITALIZATION

Taking domiciliary hospitalization without prior consent from an insurer can also lead to claim rejection. “Though some health plans and corona cover-based policies offer domiciliary hospitalization, taking up the facility requires pre-consent from insurers," said Chatterjee. “Claims can get cancelled if prior approval is not taken from the insurers."

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