Insurance coverage for pandemic, T&Cs applied

COVID-19 Top story

While most health insurance policies in India are now providing cover for COVID-19, there are many terms and conditions that arise only at the time of processing claims. 

By Jagriti Parakh

Despite insurance companies providing protection cover to individuals for medical treatment in case of coronavirus infection, many people end up paying out of their pockets as there are many exclusions in these health insurance plans where the insured person cannot raise a claim. These exclusions are specified vaguely under the terms and conditions of individual plans. For instance, if a patient is under home-quarantine or at any non-recognized facility, their claim is most likely to get rejected. 

There are so many other exceptions like this one that make the entire process of settling claims very complicated and slow-moving.

A person who tested positive for COVID-19, said, “I had an existing health insurance policy. As soon as I went for the test, I informed my insurance agent. He applied for a claim immediately for cashless treatment, but because of delay in claim processing, I had to pay my hospital bills which will be later reimbursed by the insurance company. It is an uphill task to get the claim.”

According to data compiled by the General Insurance Council, an industry body for non-life companies, as on March 30, the insurance sector got a total of 34 claims. Of this, the industry has settled only ten claims so far and the average claim amount is around Rs.1.42 lakh.

Those who already have an existing health cover must have a clear understanding of the plan, type expenses their policy would cover, the sum insured they need and much more, as there are many health insurance plans that exclude pandemic/epidemic from their coverage.

Ravi Mishra, Regional Manager, Religare Health Insurance Company, said, “The coronavirus pandemic is a healthcare emergency right now, so most insurance companies have included it under critical illness, as an exception. But these health insurance plans do not provide cover if the insured is under quarantine at home or has undergone quarantine at any non-recognized facility.” 

Although most healthcare policies are functional in case of casualty and offer death benefits to the nominee, experts say that if a person already has an existing health insurance policy, then treatment cover for COVID-19 will be also included. 

Kamal Parakh, an insurance consultant, said, “Medical insurance offers cover for 32 major critical illnesses including cancer, major heart surgeries, liver transplant, and now COVID-19. In Mediclaim plans, however, hospitalization cover is not applicable to critical illnesses.

“Most indemnity based products already cover hospitalization based expenses, so they will now also cover these expenses in case of coronavirus related treatment. It will includes coverage for in-patient care, ICU charges and quarantine period at a registered facility. Furthermore, some travel insurance products also offer the same coverage.”

Things are different if a person opts for a policy after contracting the disease. Then, another condition of the ‘waiting period’ is introduced. “In such cases, the insured will not be entitled to get coverage for the treatment. Usually, medical insurance policies come with an initial waiting period of 30 days. This implies that for getting cover for any treatment, except for emergencies like accidents, the policyholder must wait for 30 days,” he explained.

Apart from that, there are only a few insurance plans that cover the cost of screening and confirmation tests if it is negative. This is one of the main reasons why we are facing wealth and inequality consequences amid the widespread pandemic. Most people do not even get themselves tested because the screening tests are very costly—this might change with the recent Supreme Court directive that ordered private medical labs across the country to not charge patients for testing for COVID-19.

Senior citizens are more disadvantaged, as most policies are not open to people above the age of 60 or 65 years.  

Vivek Jain, who has a family floater health insurance plan, said, “I was concerned about my family’s well-being and wanted to ensure financial security in case of any untoward incident, so I called my insurance agent to find out if my existing plan cover coronavirus related treatment costs. He told me that only the members of my family below the age of 60 will be covered, which meant that my parents were excluded. Now it’s extremely tough to find a healthcare policy for senior citizens at this time.”

The novel coronavirus has affected millions of people worldwide. The contagious disease, caused by a family of viruses, results in acute respiratory illnesses including pneumonia, impaired kidney and lung functions, and even multi-organ failure. In a situation when there are uncertainty and possible health risks, people are looking through their old policy documents to see if their existing healthcare plan covers the pandemic. 

With the coronavirus outbreak, the world has been witnessing unprecedented events. It has confined people to their homes and impacted business operations, thus affecting the world economy. In times when financial problems are likely to occur, having to deal with a medical emergency without any safety cushion can be challenging.


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