Legal Remedies available to Covid-19 Patients whose medical compensation is not passed by Insurance Company

INTRODUCTION

An average person saves a lot for his future and it indeed included medical insurance. Nobody knows what future holds nor it is evitable but preparation can prevent larger event for sure. And to prevent all these one buy health insurance policy to protect them against hospitalisation. Cashless claims are preferred as the hassle of managing the hospital formality and arranging cash at the moment can lead to wastage of precious time. Few of the Insurance Companies are denying claims of Covid patients or a few of the insurance companies passing a small part of the covid 19 patient’s hospital bill.

ONSET OF COVID-19

Last year the onset of the pandemic there were several cases of COVID-19 and a tsunami of patients in hospitals. Increasing patients and scarcity of medical facilities hiked medical bills in hospitals ending empty pockets of the attendees of patients. With this insurance companies are swamped with COVID-19 patients’ insurance. Many succumbed during the process of completion of insurance while others naturally. The issue arose when the insurance companies even after having policies that were eligible for cashless settlement did not release the insurance claims and force the people to pay the full amount themselves and they will reimburse it later. Private hospitals charge much higher prices, which insurances company were unwilling to pay and covered the same by stating that they are obeying the government prescribed format.

As per the report of ‘Business Today’ Ghaziabad-based Tushar Agarwal, General Manager IT and Operations got hospitalised due to Covid-19, the hospital charged him Rs 4,200 per vial for drug Remdesivir and the insurance company only paid around Rs 2,300 saying this is the limit that the government has specified in the direction.

In another case, the amount for PPE kits was not reimbursed and in the case of the room rent, the policy has a single occupancy room limit of Rs 15,000 but due to lack of availability of single rooms, twin sharing rooms were given. The hospital in their bill charge for general ward separately to abide by the government norms and other medical bills were given separately due to which even the insurance company consider the first bill only.

Further, where there are RT-PCR tests and rapid-antigen the insurance companies are only honouring the RT-PCR test in claims settlements, and if the lab test report lacks SRF (specific reference number), which are usually not there in reports from private labs the insurance company may not settle the amount,”

THE GUIDELINES

Insurance Regulatory and Development Authority of India, herein referred to as IRDA has issued specific guidelines that says a public insurance company will pay Rs 10,000 per day for all COVID-linked treatment, Rs 15,000 per day when the patient is in ICU, and Rs 18,000 per day when he or she is on ventilator support. Though these limits are for public insurance companies and not for private insurers yet private insurers are also limiting the claims to these levels.

SOLUTION AND GRIEVANCE REDRESSAL

In general, all insurance companies sign agreements with several hospitals and form a network where eligible policyholders can be treated at comparatively lower costs this depends upon what is covered under their health or general insurance policy. Policyholders who are hospitalised at any network connected hospital will only have to bear costs that are not included under their insurance policy these costs include costs like registration and discharge charges, ambulance charges, toiletries.

Considering the arbitrary acts of the hospitals and insurers the IRDAI on 22^nd April issued direction to all network hospitals and insurers that they could not refuse any cashless insurance claims of Covid-19 patients. There was news floating on news and other social media that hospitals are not granting cashless facility for treatment of Covid-19 even though policy holders being entitled to the cashless treatment under their policy. IRDAI further stated that all network hospitals and health insurers that have signed service level agreements have to provide cashless facility for treatment to policyholders including Covid-19 patients.

DEALING HOSPITALS

It is advised by IRDAI that if any network hospital denied a cashless facility to Covid-19 patients the aggrieved policyholders can immediately send a complaint to the concerned insurance company.

Email IDs of grievance redressed officers of all the concerned companies are shared by the insurance. On clicking this link, https://www.irdai.gov.in/ADMINCMS/cms/NormalData_Layout.aspx?page=PageNo225&mid=14.2 

What if they do not respond:- If the aggrieved policyholder does not receive response from the insurer within a reasonable period of time or is not satisfied with the response of the company he/she may further approach the Grievance Redressal Cell in the Consumer Affairs Department of the IRDAI.

HOW TO MAKE A COMPLAINT

If the response from the insurance company is not satisfactory or no reasonable action has been taken the aggrieved person may further look for the following grievance addressal;

• One may approach the Grievance Redressal Officer of its branch mail ids of Grievance Redressal Officers, GRO, of all insurance companies
• A complaint in writing along with the necessary support documents should be attached.
• A return acknowledgment of the complaint with the date.

The insurance company must resolve the complaint of the aggrieved within a reasonable time.

• If the case  is not resolved within 15 days or if the aggrieved person is unhappy with the resolution aggrieved person can approach the Grievance Redressal Cell of the Consumer Affairs Department of IRDAI:
  • Call Toll Free Number 155255 (or) 1800 4254 732or
  • Send an e-mail can be sent to complaints@irdai.gov.in
• Integrated Grievance Management System (IGMS):
  • Register and monitor your complaint at irda.gov.in
• Send a letter to IRDAI with your complaint:
• Click here https://www.irdai.gov.in/ADMINCMS/cms/frmGeneral_Layout.aspx?page=PageNo3031&flag=1 to download Complaint Registration Form
• Fill and send the Complaint Registration Form along with any letter or enclosures, if felt necessary, by post or courier to:

General Manager

Consumer Affairs Department- Grievance Redressal Cell,

 Insurance Regulatory and Development Authority of India(IRDAI),

 Sy.No.115/1,Financial District, Nanakramguda,

 Gachibowli, Hyderabad-500032