A detailed guide on COVID-19 health insurance claim settlement

The COVID-19 pandemic has made people understand the need to have a health insurance policy by their side during a medical emergency. But, more importantly, the insurance claim settlement shall help pay for the treatment costs without having to go through any financial burden. As per reports, insurers are processing many COVID-19 claim settlements in India due to the widespread infection in recent years. Therefore, you must know about the COVID-19 claim settlement process to make sure you are aware of the procedures in advance.

Do health insurance policies cover COVID-19? 

Yes, health insurance policies do provide coverage for any ailment that involves hospitalization. So if you are diagnosed with COVID-19 and get admitted to the hospital, it is better to understand the health insurance claim settlement process so that you can file for a claim towards hospitalization, treatment costs, diagnostic tests, OPD procedures, etc., without any troubles.

Due to the shortage of beds in hospitals, many COVID-19 patients have been advised of home treatment. All the necessary treatment setups for starting treatment at home are provided beforehand. In this case, where hospitalization is not possible, the standard health policy offers coverage only for limited services such as diagnostic tests, medicines, doctor consults, etc., and does not cover post-recovery expenses.

For those who prefer home treatment, Corona Kavach and Corona Rakshak policies provide complete coverage allowing you to raise claims for the medical expenses, pre and post-hospitalization, home care treatment, and AYUSH treatment.

Suppose you are holding any other health policy. In that case, it is recommended to enquire with their customer care cell about the COVID-19 treatment protocol and the extent of coverage before making alternate arrangements. You may also refer to the policy documents to verify if they support home treatments or domiciliary hospitalization.

How to initiate a COVID-19 claim?

To file a claim for covid19 treatment with the insurer, there are two methods you may choose: Cashless claims and Reimbursement claims.

Cashless claim: In this type, you are not needed to pay anything to the hospital where you get hospitalized for treatment, provided the hospital is listed under the insurer’s network list. Just informing the hospital desk about your policy number or TPA membership number with relevant documents is more than enough to get things started. All the expenses during your hospitalization will be settled by the insurance company directly with the hospital.

For cashless COVID-19 claim settlement, you need to follow the below steps for smooth processing: 

• Choose to get admitted to a hospital that is part of the insurer’s network list.  
• Intimate your third-party administrator (TPA) or the insurance company about your hospitalization in advance by quoting your membership number and hospital name.
• Carry a COVID-19 positive test report issued by an ICMR-approved testing lab and doctor’s prescription recommending medical treatment.
• Sign the cashless claim request form at the hospital and submit it along with relevant medical reports.

As per the claim settlement process in insurance, your cashless claim request should be approved by the insurer within a few hours on submitting proper documents.

Reimbursement Claim: Under this claim settlement procedure, the policyholder must settle the medical expenses and get them reimbursed from the insurer, later on submitting the necessary documentation and bills. In case you get hospitalized in a non-network hospital or undergo home treatment for COVID-19, then a reimbursement claim is the only option available, which has to file in the following steps:   

• Make sure to pay all the bills to the hospital before being discharged.
• The doctor collects all the bills/ receipts & documents related to hospitalization, medicines, diagnostic tests, prescriptions, discharge summaries, etc., from the doctor.
• Remember to keep the doctor’s prescription handy for those under home treatment, which recommends home isolation and treatment for COVID-19.
• Contact the insurance company or TPA via email or hotline and quote your membership ID number to intimate about the reimbursement claim.
• Download the reimbursement form from their website, enter all the required details, attach relevant documentation and submit before 14 days of discharge.

After verification of the submitted details, the insurer or TPA shall reimburse the cost by cheque or direct credit to your bank account.

What is covered under COVID-19 claims?

Policyholders who choose to get hospitalized for covid19 treatment can expect claim settlement for room rent, doctor consultation, medicines, diagnostic tests, etc., But those who opt for home treatment may miss out on post-recovery charges, cost of food supplements, doctor/ nurse visit, etc. unless you have covid19 specific covers with your existing policy or Corona Kavach and Corona Rakshak policies.

The Corona Rakshak policy is an individual cover specifically launched to provide coverage against COVID-19 treatment costs if the policyholder was hospitalized for a minimum of 72 hours. It offers a 100% payout benefit in lump sum amount based on the chosen sum insured from a minimum of Rs. 50,000 to a maximum of Rs 2.5 lakh. You can claim for the expenses related to medical treatment, hospitalization, consumables such as PPE, masks, gloves, etc., in addition to oxygen cylinders, home-treatment expenses, doctor/ nurse visits/ consultations, etc.

Whereas Corona Kavach policy is available with a minimum sum insured of Rs. 50,000 and the maximum Rs.5,00,000, within which a policyholder can utilize the coverage for expenses towards doctor consultation, medicine costs, diagnostic tests, oxygen cylinders, pulse oximeters, etc. While self-treatment without proper medical advice is not covered under the policy, home treatment costs are covered, provided you can submit all the necessary documentation within the stipulated time to the insurer.

Filing a claim in the health insurance policy is similar to the claim settlement procedure in general insurance. But, if you are prescribed home treatment for COVID-19, remember to inform your insurer or TPA about the same in advance. This will ensure you know about the policy’s coverage limits, exclusions, and inclusions beforehand, allowing you peace of mind during the treatment phase. It should also help you in a smoother claim settlement process.