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Covid health claims of Rs 10,703 cr pending before insurers despite HC, Irdai directive

Over 3.06 lakh Covid claims for Rs 10,703 crore are pending before insurance companies as of August 6, indicating the pressure being faced by insurers despite Delhi High Court and Irdai, directing insurance firms to complete the settlement of Covid claims in an hour after discharge.

Written by George Mathew | Mumbai |
Updated: August 9, 2021 5:45:40 am
The big rise in claims even forced some insurance companies to stop issuing health policies for some periods. Many companies were even forced to go slow on issuing term policies as death claims also shot up.

With insurance claims going through the roof amid the Covid-19 pandemic, insurance companies are sitting on almost one-third of the claims submitted by patients since the pandemic hit the country in the beginning of the financial year 2020-21. Over 3.06 lakh Covid claims for Rs 10,703 crore are pending before insurance companies as on August 6, indicating the pressure being faced by insurers despite Delhi High Court and insurance regulator IRDAI directing the insurance firms to complete the settlement of Covid claims in an hour after discharge.

Health insurance companies have received a total of 23.06 lakh claims worth Rs 29,341 crore as on August 6, 2021, according to figures compiled by the General Insurance Council. However, insurance firms have settled only Rs 17,813 crore involving 18.99 claims so far.

Of the total claims, 13.19 lakh claims worth Rs 14,783 crore came between April 1 and August 6, 2021 during the financial year 2021-22 while 9.86 lakh claims for Rs 14,560 crore were reported during the financial year ended March 2021.

According to insurers, the sharp rise in Covid claims has hit them substantially. “Yes, health claims have gone up a lot. While the number of claims went up, the average cost of a covid claim is twice the size of non-covid claims. Thus, the hit has been substantial,” said Kamesh Goyal, Chairman, Digit Insurance.

The big rise in claims even forced some insurance companies to stop issuing health policies for some periods. Many companies were even forced to go slow on issuing term policies as death claims also shot up. “I’m sitting on a 400 per cent loss in Covid claims,” said the regional manager of a public sector insurer.

The General Insurance Council, the representative body of 34 general insurers in the country, has laid down a basic framework for seeking the cooperation from hospitals to implement the directives. It has asked hospitals to submit all the patient discharge documents in one go without having to be reminded of the missing documents like cashless treatment approval reference, copy of the case sheet, prescriptions, diagnostic reports, bills, discharge summary, Covid positive and the subsequent Covid negative reports. They were also advised to ensure billing done at pre-agreed rates and provide justification with supporting medical records for any co-morbidities necessarily treated.

According to the Council, when the patient’s progress is good and discharge is planned for the next day, hospitals should inform the insurance company or TPA of the impending discharge the soonest and submit the available documents and bills. “Balance documents and bills pertaining to the last 24 hours could be submitted at the discharge time so that the insurance company or TPA could also start working on the discharge simultaneously,” it had said.

Currently, insurers take up to five or six hours for settlement of hospital claims and patients are held up in the hospital during this period. Hospitals refuse to discharge patients without getting the insurer’s approval.

Earlier, the IRDAI had asked all general and health insurance companies to communicate their decision on the authorisation of cashless treatment for Covid-related claims to network providers within an hour of receiving the request. Also, they have to communicate their decision on the final discharge of patients, whose Covid claims are covered, within an hour of receiving the final bill from the hospital.

On the rise in hospitalisation costs, Goyal said, “medical inflation is real, 8 per cent in May 2021, compared to 6 per cent in Jan 2021. So yes, hospitalization costs will increase. The idea here is to have sustainable and valuable products and also make people aware of the right sum insured they should be looking at keeping the rising expenditures in mind. We also need to keep in mind that Covid has led to some billing for PPE, gloves etc which was not there before.”

Meanwhile, insurers rejected 41,763 claims worth Rs 361 crore in 2020-21 and 58,920 claims worth Rs 464 crore up to August 6 in 2021-21.

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