Unhappy with insurer's response to your Covid claim? Move the ombudsman

If your complaint has merit, the ombudsman, which is decidedly consumer-centric, could rule in your favour

Kimti Lal Khatri, 55, a resident of Malviya Nagar, New Delhi, was hospitalised for 17 days for Covid treatment. His bill came to Rs 3.2 lakh. First, his third-party administrator (TPA) informed that he would have to pay only Rs 10,700 out of his pocket. The rest would be reimbursed by the insurer. Later, he was told he would have to pay another Rs 89,000.  The snag: While the hospital charged him its own rates, the insurer was willing to reimburse at the rates fixed by the state government.

Shirley M (name changed on request), 43, a marketing executive with a Bengaluru-based information technology company, underwent home treatment for Covid. She had purchased a Corona Kavach policy from a private general insurer. She submitted a claim, along with the bills for what she had spent on doctor’s consultancy and medicines. The insurer, however, asked her for a chart of her daily fever and SPO2 levels, certified by a doctor. It also wanted a doctor’s prescription to state she had tested positive for Covid (though she had an RT-PCR positive report). “I only had two online consultations and two follow-up consultations with a doctor. At a time when doctors are so overburdened, how will it be possible for me to produce a daily chart of fever and SPO2, certified by a doctor?” she asks. When the insurer sat on her documents for a long time, she resubmitted the papers to her office for a claim under its group insurance cover. She is waiting for a response from the latter.

According to General Insurance Council (GIC) data, until April 28, about 1.1 million Covid health claims worth Rs 15,568 crore were filed with insurers. Of these, 930,729 claims worth Rs 8,918.57 crore were settled. By May 14, the numbers had shot up to 1.48 million claims amounting to Rs 22,931.63 crore. Insurers have so far settled 1.23 million claims amounting to Rs 11,784.54 crore. Note the growing gap between claims made and settled in just a fortnight.

Rising number of complaints

Customers’ woes may increase amid the second wave. “The number of complaints has been going up. Either claims are being completely rejected or there is only partial payment,” says Milind Kharat, insurance ombudsman, Mumbai.

Kharat enumerated the key issues customers are facing. One is home treatment. Some insurers say their policy does not cover home treatment and hence they reject those claims altogether.

There are also cases where the insured had a pre-existing condition, such as, say, hypertension or diabetes, which he failed to declare. Insurers reject even the Covid-related claims of such persons on the ground of ‘material non-disclosure’.

Some people may have had only mild symptoms but got hospitalised. Even in such cases, insurers sometimes dispute the claim.

There are also disputed related to partial payment of claims. “The General Insurance Council (GIC) and state governments have issued guideline rates. If the hospital bills at a rate that is higher than those rates, insurers go by the state government or GIC rate, and refuse to pay the balance,” says Kharat.   

What customers should know

Health insurance customers need to exercise a few precautions on their side so that their claims don’t get rejected. At the time of purchasing a policy, all pre-existing conditions should be declared as these can create problems later.

As part of your contingency planning, get to know the good-quality hospitals in your vicinity that are part of your insurer’s network. “Both for smoother procedures and to avail of cashless claim, you should opt for a network hospital,” says Naval Goel, founder & chief executive officer (CEO), PolicyX.com. In case that is not possible, inform your insurer at the time of admission in a non-networked hospital. Also make sure that the non-network hospital is not on your insurer’s caution list (blacklisted hospital), because it may not entertain claims from such a hospital.

Get to know the grade of room your policy entitles you to. “Avoid using a room above that grade,” says Amit Chhabra, head- health and travel insurance, Policybazaar. If your policy offers a single, standard-grade private room, and you avail of a deluxe room, your bills may get only partially reimbursed.

All newly-purchased policies come with an initial waiting period during which no ailment (only accidental injury) is covered. “In a standard health insurance policy ailments are not covered for the first 30 days. In Corona Kavach, the waiting period is 15 days,” says Sanjay Datta, chief-claims, underwriting and reinsurance, ICICI Lombard General Insurance. He further adds: “Be aware of the sub-limits and co-pay features in your policy, and also the balance sum insured left (if a claim has already been made),” adds Datta.

Maintain proper documentation or else it could become difficult to get a claim. According to a note from Edelweiss General Insurance, patients should ensure they maintain a record of all diagnostic reports for Covid like RT PCR/RAT; prescriptions; receipts of all expenses incurred on doctor consultations, other diagnostic test reports, pharmacy bills, etc. In case of a claim, inform your third-party administrator (TPA) and then upload all scanned documents to the TPA’s portal.

Seeking redress  

If your claim is rejected or partially paid, and you disagree, first seek redress with the insurer. File a complaint with the Grievance Redressal Officer (GRO) of the insurer. The insurance regulator has also set up the Integrated Grievances Management System (IGMS), an online consumer complaint registration system. Complaints registered on this portal are also sent to the insurer. If you are not satisfied with the insurer’s response, file a complaint with the ombudsman's office.

How to seek redress from the ombudsman

• At the Council of ombudsman web site, you will find the email ID for the ombudsman of your state
• Send your complaint to that email ID; you don’t need to visit the ombudsman’s office
• Send the following documents: insurer's letter of denial or partial settlement, customer’s letter to grievance officer, and the medical documents he had filed with the insurer
• Engaging a lawyer is not permitted
• An ombudsman is required to settle a claim within three months