How to file a health insurance claim in case of COVID-19 treatment at home?

India was the worst hit in the second wave of the COVID-19 pandemic, which spread across the length and breadth of the country because of the vast population. As cases multiplied drastically, the medical infrastructure in most states couldn’t get a grip on the situation leading to a shortage of hospital beds. Considering the lack of beds and medical facilities at hospitals, many patients chose to stay at home and get COVID-19 treatment. But those who opt for home treatment are worried whether their health insurance will cover the expenses towards treatment for COVID-19 at home.

Surekha Reddy, a 28-year-old game animator from Hyderabad, was diagnosed with COVID-19 at the airport while traveling to Bangalore. With no hospital beds, she was advised of home treatment by government officials. Since Surekha was living with her parents, she immediately rushed back to her house, where she intended to isolate herself and start treatment. However, while their family doctor was instructing her on the medicines to consume, lab tests were conducted from the nearest diagnostic lab. Due to proper treatment, Surekha was able to recover from COVID-19 entirely in 14 days. Although she was in-home treatment for COVID-19, her company’s health insurance provided coverage for the expenses made towards doctor’s consultation, diagnostic tests, and medicines.

Health Insurance policies for COVID-19

Generally, standard health insurance policies do not cover home treatment. A policyholder is eligible to file a claim only on minimum 24-hour hospitalization and OPD procedures. But, Corona Kavach and Corona Rakshak policies launched under the guidelines of the Insurance Regulatory and Development Authority of India (IRDAI) cover the medical expenses, pre and post-hospitalization, home care treatment, etc. and AYUSH treatment in case the policyholder tests positive for COVID-19.

While Corona Kavach is a family floater policy that covers the entire family against the COVID-19 treatment and medical expenses, Corona Rakshak is an individual policy that covers the individual only by paying a lump-sum amount on COVID-19 diagnosis. Both the policies support homecare treatment on the advice of a medical practitioner, and a claim is approved on the submission of necessary documents. These are specialized policies targeted for covid19 only, and an individual who possesses any other health policy may also buy these for additional protection unless you opt for any other new treatment for COVID-19.

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.

Documents needed for filing a claim

To claim the medical expenses towards covid19 home treatment successfully, the following need to be furnished to your insurer at the earliest, along with the health insurance claim form, for approval.

1) COVID-19 positive test report from an ICMR-approved testing lab. Only RT PCR tests having Specimen Referral Form (SRF) ID are considered valid.

2) A doctor’s prescription recommending home isolation and treatment.

Contact your health insurer with the above details by reaching them via hotline or email to understand the extent of coverage available in your existing policy.

What is the coverage? 

Under standard health insurance policies that require hospitalization, one can claim for the expenses made for doctor’s consultation, medicines, diagnostic tests, etc. However, it may not support post-recovery charges, the cost of food supplements, doctor/ nurse visits, etc., as they are usually not covered under these policies.

If the policy supports home treatment, inform the company about your home treatment for a smoother health insurance claim settlement process. The extent of coverage depends on the policy you have chosen.

For example, the Corona Kavach policy provides coverage of bills as per COVID-19 treatment guidelines for a doctor consultation, medicine, diagnostic tests, oxygen cylinders, pulse oximeters, etc. The minimum sum insured for this policy is Rs. 50,000 and the maximum Rs.5,00,000, within which one can claim coverage. Although home treatment costs are covered, the doctor should prescribe them, and self-treatment without proper medical advice is not covered.

The Corona Rakshak policy, on the other hand, is an individual cover that shall cover the cost of COVID-19 treatment if the policyholder is hospitalized for a minimum of 72 hours. Similar to Corona Kavach, the Corona Rakshak policy also covers costs of treatment, hospitalization, consumables such as PPE, masks, gloves, etc., in addition to oxygen cylinders, home-treatment expenses, doctor/ nurse visits/ consultations, etc. This being an individual policy, the sum insured ranges from Rs. 50,000 to Rs 2.5 lakh.

COVID-19 Claim Approval Status 

Expenses during medical emergencies are always unexpected and can pinch your finances if not appropriately planned. If you are also solely dependent on the claim amount, it becomes even more crucial to make sure the claim is approved. So here are few essential tips to ensure your claim request is not rejected:

• Make sure to inform your TPA or insurer about the diagnosis as soon as possible to make sure your claims move smoothly.
• Understand the features of the policy along with the inclusions, exclusions, coverage limits, waiting period, etc., so you don’t submit a claim for an uncovered service and end up getting rejected.
• Preserve all the necessary bills, documentation, doctor prescription, medicine receipts, diagnostic test reports, etc., as they are essential documents for you to submit to the insurer for proper claim settlement.
• Look at the claim settlement ratio of health insurance companies before buying the covid19 policy. Choose an insurer with high CSR as a high claim settlement rate means more confidence among policyholders, whereas a low CSR denotes a poor claim settlement rate. Going for a policy from an insurer with the best claim ratio in the health insurance industry is recommended to avoid future claim settlements.

The COVID-19 pandemic is far from over, and the threat of the virus is still at large. Therefore, protecting yourself by investing in an appropriate health insurance policy that covers hospitalization and home treatment is always better to prepare for the future.