Lok Sabha Question No. 3360 (UNSTARRED), answered on 2021-08-09
Subject: Covid Related Claims
Ministry: FINANCE
Asked by: Mahua Moitra, Gaddam Ranjith Reddy

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

## LOK SABHA UNSTARRED QUESTION NO. 3360

TO BE ANSWERED ON MONDAY, AUGUST 09, 2021/SRAVANA 18, 1943 (SAKA)

## COVID RELATED CLAIMS

## 3360. SHRIMATI MAHUA MOITRA: DR. G. RANJITH REDDY:

Will the Minister of FINANCE be pleased to state:-

- (a)  the details of COVID related claims denied either totally or partially to policy holders;
- (b)  the details of cashless policies who were forced to pay upfront for treatment of COVID;
- (c)  the details of action taken/being taken by the Government against insurance companies for their denial of claims as well as hardship caused to their policy holders; and
- (d)  the  details  of  action  taken/being  taken  by  the  Government  to  reimburse  the  desired claims of the policy holders?

## ANSWER

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

(a) to (d): 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.

As  regards  cashless  treatment,  as  per  regulation  30  of  the  said  regulations,  cashless treatment  facility  is  offered  only  at  medical  establishments  which  have  entered  into  an agreement with the insurer to extend such services ('network providers'), and a health policy offers  reimbursement  of  treatment  at  other  medical  establishments.  Further,  as  per  the procedure provided under IRDAI's Master Circular on Standardisation of Health Insurance Products,  which  is  issued  under  the  Insurance  Act  and  the  said  regulations,  cashless treatment  is  subject  to  pre-authorisation  by  the  insurer  or  its  authorised  Third  Party Administrator (TPA), wherein an Insured person can avail the cashless after providing the relevant medical details to the satisfaction of TPA. In such a scenario, the insured person may  obtain  treatment  and  submit  the  claim  to  the  insurer/TPA  for  reimbursement.  To facilitate  expeditious  intimation  regarding  availability  of  cashless  treatment  at  specified establishments,  IRDAI  has  asked  all  general  and  health  insurers  to  communicate  their decision  on  authorisation  for  cashless  treatment  for  COVID-19  claims  to  the  network providers  within  60  minutes  of  receipt  of  request  for  authorisation  accompanied  by  all necessary requirements from the network providers.

Thus, a health insurance policyholder is entitled to reimbursement of treatment costs at any medical  establishment,  including  in  respect  of  treatment  of  COVID,  and  to  cashless treatment at specific medical establishments after requesting pre-authorisation accompanied by all necessary medical details from the establishment and receiving such authorisation.

A  policyholder  who  has  a  grievance  regarding  a  claim,  can  represent  to  the  Grievance Redressal  Officer  of  the  insurer  concerned  and  upon  either  not  being  satisfied  with  the response or expiry of one month, represent to the Insurance Ombudsman, who is authorised to award compensation to policyholders after due hearing.

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

- (i) All general and health insurers have been instructed that any claim to be repudiated has 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.
- (iii)  IRDAI's  Guidelines  on  Standardisation  of  General  Terms  and  Clauses  in  Health Insurance Policy Contract now require insurers to settle claims within 30 days of receipt of the last necessary document.
- (iv) IRDAI has issued a circular allowing collection of health premiums in instalments to ease payment burden.
- (v)  Government provided a grace period till 15.5.2020 for paying health premium for policies falling due between 25.3.2020 and 3.5.2020, to enable continuity of cover.
- (vi) Standard  COVID  related  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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