Arun Shinde (name changed) tested positive for coronavirus and got admitted to a private hospital in Mumbai on April 2. His treatment went on for 17 days and he got discharged on April 19. His total hospital bill stood at Rs 2.87 lakh. Shinde had a mediclaim with an insurer for a sum insured of Rs 5 lakh, but he only received Rs 1.43 lakh. The insurance firm deducted a whopping Rs 1.44 lakh as part of 'non-payable items' that included PPE kits, N-95 masks and face shields etc.
Technically, the insurance firm played by the rules. Since insurers only cover the treatment cost, not disposable or consumable items that are meant for patients' personal use, the said insurance firm deducted the cost of PPE kit. However, coronavirus is an exceptional case in which consumables such as PPEs comprise major chunk of the hospital bill.
"Disposable items cost no more than 10 per cent or so for other hospital treatment. In case of COVID-19 it is as high as 50 per cent of the total treatment cost. The regulator and insurance companies must look into it at the earliest," says Virendra Suri, general insurance expert at Insurance Samadhan, a Delhi-based grievance redressal firm.
Insurance Samadhan has written to the concerned insurance company on behalf of Shinde, which is yet to respond to the complaint. Secondly, private hospitals seem to be charging for PPE kits from all patients even though one doctor tends to multiple patients wearing one PPE.
"Hospitals are not wrong in charging for the PPE cost from patients, but when a doctor wears a PPE, she examines multiple patients wearing it in a matter of three-four hours unlike gloves, which she would typically dispose after tending to one patient. So, only a percentage of the PPE cost should be added in the bill, not the full amount," Suri explains. In another case, one of the hospitals in Maharashtra, which had charged for the PPE kit from a patient, 'promised to give back' the amount after his insurance company raised the matter with the hospital. Going by a local media report, one of the insurance staff recorded a video accusing the hospital of overcharging the patient and circulated it on social media.
The PPE conundrum in insurance
As claims requests for coronavirus treatment are on the rise, the PPE cost is emerging as a big conundrum. A spokesperson from an insurance company, who didn't wish to be named, said that negotiations are on among regulator, insurance companies and hospitals to come up with a standardised coronavirus treatment cost. "Talks are going on to launch a standard package across private hospitals that will subsume all expenses from room charges to PPE kits etc," he said.
Jayan Mathews, Co-founder and Chief Product Officer at healthcare financing platform Vital, expects the stakeholders to reach an agreement soon. "Currently, there are no standard treatment protocols for COVID-19. But, discussions are underway between the authorities, providers and insurers to come up with a standard pricing and protocols to follow with respect to COVID-19 treatments. Agreements could be fixed for consumable and non-consumable items. If that happens, it may help in addressing the PPE kit issue."
This is not the only issue in claims settlement. Shinde had, in fact, approached Insurance Samadhan after his insurer delayed the claims reimbursement on the grounds that the patient had not submitted IPD (indoor patient documents) papers. The grievance redressal firm took the matter in its hands and managed to settle the claim with the insurer. "The government has restricted hospitals to release IPD papers for coronavirus patients. We highlighted it to the insurer and declared that rest of original bills and papers will be submitted soon after the lockdown eases," Suri said. Insurance Samadhan, which charges Rs 500 registration fees and 9 per cent of claims amount from the customers, waived off the fees for the said patient.
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