How to file a health insurance claim for Covid-19

Covid-19 cases are on a steady rise in India. On Sunday, the country reported the largest daily increase so far with over 1500 new cases. To provide some relief to the infected policyholders, the Insurance Regulatory and Development Authority of India (Irdai) on Saturday said that health insurers have to decide on the authorization for cashless claims to the hospital within two hours from the time of receipt of authorization request. Insurers will also have to communicate their decision on discharge within two hours of receiving the receipt of final bill.

“Decision on authorization for cashless treatment shall be communicated to the network provider (hospital) within two hours from the time of receipt of authorization request and last necessary requirement from the hospital either to the insurer or to the TPA whichever is earlier,” said the regulator in a circular. Insurers have also been asked to settle Covid-19 claims on priority basis. “Irdai wants insurers to pay the hospitals faster because most hospitals are dealing with liquidity crunch as planned surgeries have dropped and occupancy rates have gone down. Hospitals have approached Irdai to ensure the claims are settled and that’s where the announcement has come from,” said Dr. Nayan Shah, managing director, Paramount Health Services (TPA) Pvt Ltd.

If you do test positive for covid-19 and are getting treated in a private hospital, here’s how you can go about filing your insurance claim.

Make sure you have all required documents in place. Customer ID proof, health insurance card or policy and all recent treatment records prior to admission are important. In case you are filing a reimbursement claim then all hospitalization expense bills, payment receipts, diagnostic reports including the Covid-19 test report and claim form should be kept handy.

“The costs of admissible medical expenses during the course of treatment including the treatment during quarantine period shall be settled in accordance to the applicable terms and conditions of the policy contract and the extant regulatory framework,” said Bisheshwari Singh, chief marketing officer, Universal Sompo General Insurance Co Ltd.

Cashless claims: In case of a cashless claim, the hospital settles the bill directly with the insurer and there isn’t much you’ll have to do because all relevant documents will be shared by the hospital. To ensure there is no back and forth, make sure all the documents and bills are in order. “If the total bill goes beyond the sum insured then the policyholder will have to pay out of his pocket directly to the hospital,” said Shah.

Reimbursement claims: In this case, you will have to pay the hospital bills directly and then get them reimbursed. You will be required to fill a claim form and upload a list of documents such as the discharge summary, diagnostic tests and reports, their bills, treatment charges and doctor’s prescription. In the form you will also have to fill in the claims acknowledgement number that insurer gives you when you get hospitalized and inform the insurer that you’ll be making a claim.

Most TPAs with technical support have provisioned for the documents to be uploaded online which will later be scrutinized and processed. Some insurance companies will disburse the claim amount based on scanned copies uploaded online and some might process the claim but disburse the payment only once the original documents are submitted. “Since even courier services are down, TPAs that have a good digital architecture have allowed policyholders to upload the documents online. TPAs have been instructed to process the claims in 3-4 days so that insurers can settle the claims faster,” said Shah. You may also be asked to furnish a cancelled cheque or fill an electronic clearance service form by the insurer in order to transfer the claim amount into your bank account.