Lok Sabha Question No. 2187 (UNSTARRED), answered on 2021-08-02
Subject: Non Coverage of Covid Treatment
Ministry: FINANCE
Asked by: Gaddam Ranjith Reddy

## GOVERNMENT OF INDIA MINISTRY OF FINANCE DEPARTMENT OF FINANCIAL SERVICES

## LOK SABHA UNSTARRED QUESTION NO. 2187

TO BE ANSWERED ON MONDAY, AUGUST 02, 2021/SRAVANA 11, 1943 (SAKA)

## NON COVERAGE OF COVID TREATMENT

## 2187. DR. G. RANJITH REDDY:

Will the Minister of FINANCE be pleased to state:-

- (a) the  details  of  how  the  Ministry  looks  at  the  COVID  patients  paying  40  per  cent treatment cost from their pockets in spite of having health insurance policies;
- (b) the  reasons  that  IRDA,  the  Ministry  and  other  agencies  are  not  able  to  rein  in insurance  companies  which  are  not  aligning  payouts  to  the  actual  amount  for COVID treatment;
- (c) the reasons as to why insurance companies are excluding overhead consumables such as PPE kits, gloves, masks, telemedicine, etc.;
- (d) whether the Ministry or IRDA has intervened on this and persuaded or convinced insurance companies on this; and
- (e) if so, the details thereof?

## ANSWER

## MINISTER OF STATE IN THE MINISTRY OF FINANCE (DR. BHAGWAT KARAD)

(a): (a)  to  (e):  Health  insurance  claims  are  settled  by  insurers  as  per  the  terms  and conditions of the health insurance policy contract. As per regulation 27(vi) of the Insurance Regulatory  and  Development  Authority  of  India  (Health  Insurance)  Regulations,  2016, read with the Guidelines on Standard Individual Health Insurance Product issued by the Insurance  Regulatory  and  Development  Authority  of  India  (IRDAI),  if  during  the  policy period one or more insured person is required to be hospitalised for treatment of an illness or  injury  at  a  hospital  or  daycare  centre  following  medical  advice  of  a  duly  qualified medical practitioner, the company shall indemnify medically necessary expenses towards the coverage mentioned in the policy schedule, with the proviso that the amount payable shall  be  subject  to  the  terms  of  coverage  (including  any  co-payment  and  sub-limits), exclusions  and  conditions  given  therein.  The  maximum  liability  of  the  insurer  under  all such claims during each policy year is the sum insured opted and cumulative bonus, if any, specified in the policy schedule.

Thus, a health insurance policyholder is entitled to coverage of treatment cost, including in respect of treatment of COVID, as per the above guidelines and subject to the terms of coverage given in the schedule to the policy issued to him/her.

IRDAI has informed that the since the onset of the pandemic it has taken, inter alia , the following steps for speedy settlement of COVID related health insurance claims:

- (i)  On 4.3.2020, it issued norms to all general and health insurers instructing them that any  claim  to  be  repudiated  had  to  be  reviewed  by  the  apex  level  claims  review committee of the insurer.
- (ii)  All  insurers  have  been  advised  to  publish  frequently  asked  questions  (FAQs)  on COVID-19  claims  on  their  respective  websites  and  to  be  sensitive  towards  the requirements of policyholders in settlement of claims.

A number of other measures have also been taken to help policyholders in the context of the pandemic.These include the following:

- (a) An  Advisory  has  been  issued  by  IRDAI  for  expeditious  settlement  of  health insurance  claims,  including  through  authorisation  of  cashless  claims  within  one hour from the time of receipt of                   pre-authorisation request and last necessary requirement from the hospital either to the insurer or to the third party administrator, whichever is earlier.
- (b) The  Guidelines  on  Standardization  of  General  Terms  and  Clauses  in  Health Insurance  Policy  Contract  issued  by  IRDAI  now  require  the  insurer  to  settle  a claim within 30 days of receipt of the last necessary document.
- (c) IRDAI has issued a circular to allow to collecting of health insurance premiums in instalments, in order to ease the payment of health insurance premiums.
- (d) Grace period till 15.5.2020 was given by the Government for payment of premium for health and motor (third party) vehicle insurance falling due between 25.3.2020 and 3.5.2020, to enable continuity of insurance cover.
- (e) Standard  health  insurance  products  have  been  launched  for  covering  COVID (namely,  Arogya  Sanjeevani,  Corona  Kavach  and  Corona  Rakshak),  which  are simple and easy to understand and have a simplified claim settlement process.

Enabled by the above interventions, 17.94 lakh COVID related claims, amounting to Rs 21,837 crore, have been settled between 1.4.2020 and 15.7.2021.

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