○ I am a Covid warrior doctor trying to serve the nation relentlessly and it’s really disappointing that in that process, if I get infected and admitted (to hospital) then also I have to pay such a huge amount of (Rs) 40,000-plus... from my own pocket in spite of having an insurance where from I never also had any previous claim. Please do reconsider my case.

This was an appeal to a government insurance company early this month from a doctor who is originally from Calcutta, now based in Delhi. The doctor was admitted to a private hospital in Delhi with Covid.

○ Kindly note, though Covid-19 positive, since patient is mild symptomatic, patient can well be managed under home isolation or quarantine. Hence cashless denied.

A private hospital in Calcutta got this message in May after it sent the treatment details of a 53-year-old man admitted with Covid to a private insurance company for reimbursement.

Health insurance companies denying claims for cashless admission or reimbursing an amount much less than the insured sum is nothing new, but the problem felt much worse during the second wave of Covid-19 infections when people needed health cover more than ever before.

The long stay at hospital meant huge bills for many patients, and the denial of cashless claims or release of an amount much less than the sum assured is only compounding the agony of the families.

Several hospitals said they were facing problems as many patients’ relatives were blaming them and getting into arguments when the claims were being denied.

Metro spoke to hospitals and insurance officials and they have their reasons and explanations for people not getting reimbursed. But ultimately, it is the patient who suffers.

Consumers suffer

Sandip Bhunia, an executive at a private firm in Calcutta, had got admitted to a private hospital in July 2020 after testing positive for Covid-19. He had a health insurance policy with a private company, under which he was entitled to get a daily allowance of Rs 10,000 for four days when he was admitted to hospital.

“I had claimed the amount through an online application in August last year and attached the documents. There was no reply from the insurance company and so, I started sending them mails from October,” said Bhunia.

“In February, I had the due date for paying this year’s premium. I told my insurance agent that the company has not yet paid my claim but he told me not to worry. So, I paid my premium,” he said.

“After months, they sought my Covid-positive report and some other documents, in one of which it was mentioned that I was having statin (a drug to lower the cholesterol level). The insurance company rejected my claim saying that I had a pre-existing disease while I had taken the policy. I had submitted all documents of my medical conditions while taking the policy,” said Bhunia.

A doctor based in Calcutta was not given full reimbursement by a public sector health insurance company on the grounds that his bed charges were more than what he was eligible for. But in his mail to the insurance company, the doctor wrote that he stayed in a general bed and “nothing close to fancy or even HDU or suite or single cabin”.

The insurance company also did not reimburse charges for visits by the resident medical officers and dieti-cians during his stay at the hospital, the doctor wrote in his mail.

A 37-year-old woman who was admitted to a private hospital in Calcutta with Covid was denied a cashless facility.

“On scrutiny of the available medical documents, it is observed that the patient is clinically stable with overall fair general condition. The evaluation of her respiratory system did not reveal any medically significant findings. Going by the advisory of the ministry of health and family welfare the clinical picture can be categorised as mild Covid case and it requires primarily isolation at Covid care centre with medical counselling. In clinically mild cases, following the medical advice with proper isolation has been established as an

adequate regimen to recover from the contagion without necessitating hospitalisation. The ministry of health and family welfare has advised hospitalisation only in moderate to severe cases,” the insurance company wrote as explanation.

What hospitals say

Several private hospitals said they were seeing many applications for cashless facilities for Covid patients being denied or patients being given minimal reimbursements.

“Claims of many patients are being denied on the grounds that they had mild symptoms and did not need admission at a hospital. The insurance companies are citing government advisories. But there are many aged patients with comorbidites whose conditions can get worse staying at home,” said Chandramouli Bhattacharya, a consultant in tropical medicine and infectious diseases.

“I have seen many cases where a person with mild Covid was discharged from the hospital after two or three days because their oxygen saturation level was normal and they didn’t run a temperature. But after a few days, they got readmitted with fever and falling oxygen saturation,” said Bhattacharya.

Hospital officials said the problem of settling claims was not so much with surgeries and procedures for which there are packages.

“In such cases, the claims are settled without much hassle. But the problem is acute in settling claims for medical treatments where there are no such packages. For Covid, patients need medical care and often a long stay in an ICU, which makes the bill high,” said R. Venkatesh, regional director, east, Naryana Health, which has four hospitals in Calcutta, Howrah and North 24-Parganas.

Also, the costs incurred on oxygen, masks and other items are non-admissible.

An official of another private hospital said a big problem was the reimbursement for bed charges. Usually, an insurance company allows one per cent of the sum insured for general beds and two per cent for critical care beds.

“This has been the norm for decades but bed charges actually go up by 10 to 15 per cent every year as hospitals cover rising operational costs. But in most cases the insured amount remains static. So, the gap between actual bed charge and the reimbursed amount is increasing,” said Sudipta Mitra, chief executive, Peerless Hospital.

On an average, at Calcutta’s big private hospitals, general bed charges vary between Rs 2,500 and Rs 4,000 a day. The critical care beds range between Rs 8,000 and Rs 15,000 daily. So, a person with an insured amount of Rs 1 lakh would not get more than Rs 1,000 per day for general beds and Rs 2,000 for critical care beds.

Insurance companies

Several insurance companies said they “follow rules” and that hospitals often don’t send all documents, which creates confusion. Some of them said the problem was more acute in Calcutta because many people had comparatively less amounts as sum assured.

A recent survey by National Insurance Company revealed that 40 per cent of its policy-holders had insured amounts between Rs 50,000 and Rs 1 lakh.

“In most policies, the premium goes up by 30 to 40 per cent after a person turns 50 or 55. So, this is detrimental to many having large sums insured,” said Saurav Kariwala, assistant manager (health), National Insurance Company Ltd, Calcutta.

He also blamed the hospitals for differential charging.

“Same investigations cost more if the patient is admitted in higher bed categories at many private hospitals. Why should we reimburse a higher amount for the same investigations?” Kariwala asked.

Regarding Covid treatment, an official of a private insurance company said those who had taken the Corona Kavach policy got maximum reimbursements because under it, there was no cap on bed charges.

Officials said in the past couple of years, the insurance industry has grown as more people took policies or enhanced the sum insured.