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COVID-19 Patients Caught in the Middle of Tussle Between Private Insurers, Hospitals

COVID-19 Patients Caught in the Middle of Tussle Between Private Insurers, Hospitals

Medical workers in PPE attend to a patient suffering from COVID-19 at an ICU of the Max Smart Super Speciality Hospital, New Delhi, May 2020. Photo: Reuters/Danish Siddiqui.

New Delhi: Owning health insurance has not been a saving grace for many of India’s COVID-19 patients who have needed hospitalisation. According to a report in IndiaSpend, patients are finding that their insurance claims are being turned down for various reasons – high prices charged by private hospitals, the fact that their COVID-19 was ‘mild’ and the existence of other ailments not previously disclosed to the insurance companies.

Out-of-pocket expenditure for healthcare has always been high in India, and the fact that private hospitals have milked this for all it’s worth has been well-reported in the past. Perhaps due to this state of affairs, the demand for health insurance rose as the novel coronavirus spread across India, and several insurance companies began to sell new insurance products aimed directly at COVID-19 coverage.

Across the spectrum of society, awareness on the importance of health insurance was high. In July, for instance, truckers’ associations planned a protest to demand health insurance, since they were deemed essential service workers and had to work through the lockdown.

But the last few months have shown, according to IndiaSpend, that insurance companies aren’t ready to pay all the COVID-19 claims they have been getting. There are competing interests here. Private hospitals and healthcare providers believe the government’s price caps on COVID-19 treatment are unfair, and shouldn’t apply to those who have insurance. Insurance companies, on the other hand, haven’t got the chance to really understand the risks and costs associated with COVID-19 coverage. They want to pay only the capped rates, especially as they expect the number of claims to rise.

“Private hospitals over-hospitalise patients and this is a problem for insurance companies who are then forced to insure these costs,” S. Prakash, managing director of Star Health and Allied Insurance, told IndiaSpend. “Just like the insurance sector is regulated, private hospitals also need to come under a specific regulator for their prices.”


Impact on patients

Caught in the middle of this are the patients. They are being handed substantial bills by private hospitals, and then facing insurance companies that are unwilling to pay up.

The Insurance Regulatory and Development Authority of India (IRDAI), IndiaSpend reports, saw this coming and issued two important directives – first saying that any insurance cover that included hospitalisation would cover COVID-19, and then asking companies to address COVID-19-related claims simply and with an easy process. These directives, however, are yet to make patients’ lives easier.

Several patients have been complaining about this scenario, but no resolution has been found yet. For example, Sunny Guliyani’s 61-year-old mother was admitted to Delhi’s Moolchand Hospital after testing positive for COVID-19, per IndiaSpend. According to the report:

She was hospitalised for 10 days and the family was billed Rs 3.73 lakh for her treatment and stay. Initially, Guliyani was not worried because his mother had an insurance cover of Rs 5 lakh.

At the billing counter, Guliyani realised HDFC ERGO that had insured his mother would only pay Rs 1.24 lakh. The company said this would be the price under the Delhi government’s capped rates. But the hospital argued that lower rates are only available to those who are uninsured, Guliyani told IndiaSpend.

Unaware of who will reimburse him now, Guliyani has complained to several authorities, including the government, but to no avail. Patients like him have even approached the IRDAI and even courts to try and find a resolution to the high prices being charged and insurance claims not being paid. There is even an ongoing petition at the Supreme Court on the matter.

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