Rs 6,700 crore pending COVID-19 claims; only 57% settled so far

The second wave of COVID-19 has burdened the healthcare ecosystem with insurance claims facing huge delays, among other issues. Out of Rs 15,700 crore COVID-19 claims filed with the insurance companies, only 57 per cent or Rs 9,000 crore has been settled so far as of April 2021, informs an industry source. The pending claims stand at Rs 6,700 crore compared to Rs 6,660 as of March 2021.

"Pending cases may include cashless claims for which company is in the process of releasing the amount payable to hospitals and claims for which insured is claiming reimbursement from Insurers," says the industry source.

April recorded a 22 per cent jump in the number of COVID-19 insurance claims filed with insurers at 11,18,500 compared to 9,17,000 cases as of March 2021.

Besides delays, customers are facing issues in getting approval for cashless claims. "Some hospitals will tell you upfront that beds are not available. From the backdoor you'll be informed that if you pay cash, you'll be admitted right then," says a Delhi-based insurance agent who didn't wish to be named.

Another major challenge is insured receiving only a small portion of claims amount. There are numerous cases in which policyholders have received only about 50 per cent of the total medical bill. For example, if your hospital bill amounts to Rs 8 lakh, the insurer may cover you for Rs 4-4.5 lakh.

"There were four heads in my hospital bill apart from consumables - room rent, Covid ward charges, special Covid care and doctor visits. When you are already charging me for the room rent, why are you slapping extra charges for Covid ward and Covid care? My mother told me that one doctor was available all the time. No other Covid specialist visited ever. But they charged me extra for visits by a Covid specialist," says a Mumbai-based stock analyst whose mother was hospitalised.

"I don't blame insurance companies because they were following a pre-defined contract, but hospitals are making their own rules, flouting government guidelines," he adds.

Consumables are another challenge. The hospitals continue to charge individually for consumables such as PPE kits (that too twice or thrice a day) even as a doctor may examine all patients in a ward wearing the same kit. The GIC has fixed a limit of about Rs 1,200 for PPE kit charges per day. Patients are being charged for it at much higher prices, which insurance policies do not cover.

"Consumables form a large chunk of the claim amount. I know a case in which nearly Rs 4 lakh of Rs 7 lakh was charged for consumables and special COVID-19 care, while room rent, medicines and active line of treatment comprised just Rs 3 lakh," says Jayesh Gadekar, Head, Health & Benefits, Innovative Solutions, Global Insurance Brokers Pvt. Ltd.

"Room rent due to special Covid care, cost of medicines and bed charges have shot up. Insurance companies will not pay for it. They are not wrong. They will settle it as per GIC guidelines," he adds.

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