Many cashless insurance claims of Covid patients are being rejected during the third wave, hospitals and insurance companies said.
In the first two waves, too, there were many rejections but this time the reasons are different.
Officials of private hospitals said that among the claims being rejected were of patients with mild symptoms who could be treated at home and those who were undergoing the monoclonal antibody cocktail therapy.
Allegations abound that some insurance companies are refusing to reimburse costs of Covid treatment of patients who are getting admitted to hospital for other ailments but are testing positive for the coronavirus during routine pre-admission screening.
“Omicron (the variant of the coronavirus that is driving the current surge) being highly contagious, many people are scared that they could spread the virus to others in the family. (So they are getting admitted to hospital.) This became a social problem, which the insurance companies overlooked,” said Sudipta Mitra, chief executive of Peerless Hospital.
Cardiologist Devanshu Ghosh Roy, 61, had tested positive for Covid and had high-grade fever. His oxygen saturation level was fluctuating between 92 and 93.
“I have several comorbidities. So after a couple of days at home, my family members asked me to get admitted. During admission, my oxygen saturation level was 91,” Ghosh Roy said on Monday.
He was admitted to Peerless Hospital on January 10 and discharged after three days.
The treating doctor advised a monoclonal antibody cocktail for the cardiologist. “The doctor said it was a fit case for administering the cocktail drug,” said Ghosh Roy.
However, the insurance company rejected his claim on the ground that hospitalisation was not required for the cocktail therapy.
Subir Baral, 38, a resident of Behala in southwest Kolkata, suffered from Covid pneumonia and was admitted to Narayan Memorial Hospital on January 9.
“I have a personal health insurance policy of Rs 1 crore, for which I have paid advance premium for another two years. According to the policy clauses, I am entitled to a private room in the hospital,” said Baral.
But the private insurance company rejected his cashless claim of Rs 1.85 lakh.
“They wanted a proper certification from the doctor explaining why I required admission. I sent the required certificate and asked for reconsideration. But it was still rejected,” said Baral.
Then he used his corporate insurance policy but had to pay Rs 55,000 from his pocket. “In the corporate policy, I am entitled to a general ward bed. So, I had to pay the difference,” he said.
According to the Union health ministry’s guideline, a Covid patient can be admitted if his or her oxygen saturation level is between 90 and 93 per cent on room air, has a respiratory rate of 24 or more per minute and suffers from breathlessness.
“Insurance companies are rejecting claims despite patients getting admitted with such symptoms,” said an official of Narayan Memorial Hospital, Behala.
An official of National Insurance Co Ltd said this time the rejections were mainly because people with mild symptoms were getting admitted.
“The insurance claims went up manifold in the first half of January. Between December 15 and 31, there were 600 claims from Covid patients. Between January 1 and 15, the figure shot up to 3,000,” said Saurav Kariwala, assistant manager, medical, National Insurance Co. He said around 20 per cent of the claims for cashless facilities were rejected because the insurance company felt that the patient could have stayed in home isolation.
“For monoclonal antibody cocktail, the Insurance Regulatory and Development Authority of India issued a circular urging insurance companies not to reject claims. However, in many cases the drugs are administered without overnight admission,” he said.
An official of Peerless Hospital said this time many patients with mild or moderate symptoms were being admitted because of comorbidities.
Sudipta Mitra, chief executive of Peerless Hospital, said many patients with other ailments incidentally tested positive for Covid. “We had to get some particular tests for Covid done for these patients. To do a procedure, some disposable items have to be used. The insurance companies are rejecting such claims and paying only for the ailment for which the patient got treated,” he said.
Around 25 cashless insurance claims of Covid patients admitted to Peerless Hospital were rejected in January.