Covid-19: Steps to take if hospitals deny cashless claims

After nearly four sleepless nights when Indore’s Susheel Sharma (name changed) was finally able to breathe without artificial oxygen support, his family members sensed relief but momentarily. Soon, the hospital bills started flowing one after the other and expenses made in the rush hours a few days back to buy Remdesivir doses, oxygen cylinders, etc., were recalled on paper.

The medical expenses in four days crossed the one-lakh limit and, as doctors suggested, Sharma was to remain in the hospital for next one week for further observation. The family members quickly tried to claim the medical insurance – hoping it will come to aid as briefed when the policy was bought a few years ago.

Flood of bills

The customer care, at the third party administrator, redirected the call several times until someone finally registered to hear Sharma’s family. “Ask the hospital to forward us the bills. Only then can we help,” the phone was cut immediately. Navigating through the hospital corridors that had Covid-19 infected patients in all corners, the family reached the insurance desk which denied cashless payment outright.

“We can forward the bills to the insurance company only after the patient gets discharged. Until then, you’ll have to make all the payments to continue treatment,” the staff stated. But the family needed financial aid right away. They made several calls, pleaded the hospital authorities but in vain.

The second wave of Covid-19 isn’t merely spreading at a fast pace but is also very lethal this time around. With the entrance of several mutants, the virus ain’t as kind as last year when patients recovered after a 10-14 day isolation and regular medicines.

As many as 1,95,123 people have died due to the pathogen as on April 26 – out of 2,812 fatalities were report in past 24 hours itself, the Health Ministry said.

In this scenario, how do the family members of infected patients claim a medical insurance? Several reports indicate patients are being denied cashless insurance claims for treatment at network hospitals.

“Cashless (insurance is) available at networked or even temporary hospitals. IRDAI shall direct companies to prioritise authorisations and settlements of Covid cases,” Finance Minister Nirmala Sitharaman assured after speaking to the Insurance Regulatory and Development Authority of India (IRDAI) chairman last week.

The insurance regulatory issued an immediate advisory that reiterated FM Sitharaman’s instructions in guidelines. However, complaints of hospitals refusing to accept cashless claims have only risen in the recent times.

Redressal system

According to IRDAI’s latest directive, network hospitals (those who signed service level agreement with health insurance companies) cannot refuse cashless insurance claims of Covid-19 patients.

“There are some reports that some hospitals are not granting cashless facility for treatment of Covid-19 despite policyholders being entitled to the cashless treatment under their policy. In this regard, it is clarified that where insurers have an arrangement with the hospitals for providing cashless facility, such network hospitals are obligated to provide cashless treatment for all treatments including treatment for Covid-19,” IRDAI clarified.

But if hospitals continue to deny cashless claim, the insurance body suggested policyholders to register a complaint with the insurance company. It shared email IDs of grievance redressal officers of insurance companies.

“If they do not receive a response from the insurer within a reasonable period of time or are dissatisfied with the response of the company, they may approach the Grievance Redressal Cell in the Consumer Affairs Department of the IRDAI. Complainants are requested to submit complete details of the complaint as required in the complaint registration form put on the IRDAI website policyholder.gov.in (http://www.policyholder.gov.in/Report.aspx#),” IRDAI stated.

Insurance companies are extremely overburdened due to a sharp rise in Covid-19 cases and most patients being hospitalised as preventive precaution. However, one must stay well-informed of their rights and claim cashless cover if and when required.