Medical insurers rejecting claims over hospital stay of some Covid patients

Nagpur: Getting a hospital bed may not be a big problem for a Covid patient now, but a refund from the insurer may be.

When Covid cases were at the peak a few months ago, there was a rush of patients at hospitals. Even as hospitals were reluctant to offer cashless treatment, medical refund was available after deductions, which went up to 40% to 50% of the bill. These days, insurance companies are denying the entire claim, as they are questioning the very need for hospitalization of a patient in some cases.

The claims are being approved only if the insurers’ panel of doctors finds it a fit case to be admitted. The claims are being rejected on the grounds that the patient could have even been treated at home. Sources in hospitals here said the insurers have their own norms, which often overrule their doctors’ judgment. As a number of such cases have come up, the Vidarbha Hospitals Association (VHA) has taken up the issue with the divisional commissioner, seeking his help.

The letter says, “Even if the bills are made according to the capped rates, the insurance companies are decreeing on their own that the patient should have been treated in a general ward or at home on OPD basis. This creates unwanted acrimony with relatives at the time of discharge. The ethical discretion of placing a patient in home treatment, general bed or an ICU lies with the doctors, and neither the hospital administration nor the insurer have the right to opine.”

Dr Anup Marar, convener of VHA, said the insurers apply their own criterion for the need of hospitalization, which leads to friction with the hospital. Generally, the lung involvement, co-morbidities and age factor are considered for admitting a patient in hospital. It all depends on the doctor’s judgment, he said. In the earlier days, almost every patient used to prefer getting admitted to the hospital to remain on the safe side. This had also led to shortage of beds. Now, as home treatment can also happen, the insurance companies have taken such a stance, said sources.

“There have been cases in a couple of hospitals where the insurers have rejected the claims entirely. This may be because the company’s doctors have thought that the case did not need hospitalization. However, views of the doctors treating the patient should also be considered,” said a general insurance agent.