Covid-19 treatment: Insurers ‘silent’ on ‘no cover’ for new therapies

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New therapies for the treatment of Covid-19 may hold out promise, but the problem is they are pricey and not covered by general health and even coronavirus-specific insurance policies.

Several private hospitals are using these new therapies and drugs in view of their ‘efficacy’. However, some of these therapies are expensive — costing patients anything between ₹60,000 and ₹5 lakh, depending on the patient’s level of infection, according to information provided by hospitals.

A senior official of a leading private general insurer told BusinessLine that the monoclonal antibody therapy and cocktail treatments, for instance, are not covered under the health policies. “This is because most of these treatments do not involve hospitalisation and also are not on the list of drugs/treatments advised by the Indian Council of Medical Research,’’ he said.

Monoclonal antibodies

But there is an increasing recourse to new therapies. According to K Subba Reddy, Head of Critical Care, Apollo Hospitals, new therapies include the use of monoclonal antibodies, Tocilizumab, Barcitinib, Tofatanib, Anakinra, stem cell therapy, low-dose radiation, colchicine, cytokine filter, and 2 Deoxy Glucose.

“Out of all these, monoclonal antibodies are most commonly used. Barcitinib is used only in those who go onto a ventilator (20 per cent of patients0, or ECMO patients (5 per cent),’’ Reddy said.

Lack of clarity

There is a lack of clarity on the applicability of insurance cover on many of these therapies which is reflected in the ‘silence’ of general insurers on the issue. Out of five general insurers contacted by BusinessLine, only two shared information, off the record.

“There has been a huge payout of claims on account of Covid cover being offered under specific policies such as Corona Kavach (mandated by the insurance regulator) and general health insurance. There is a need to tread cautiously, and regulatory clarity is needed on the matter for the benefit of all stakeholders,’’ said the chief of underwriting of a private insurer adding that “there are fake certificates and claims, too, in some cases of Covid cover.’’

But patients are at the receiving end as the final settlement in a majority of Covid cases is only in the range of 50-65 per cent of the claim.

 

 

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How you can insure yourself from Covid

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With the second wave of Covid raging across the country, many are looking to buy a health cover or enhance the same. According to data from Policybazaar.com, 90 per cent of their customers who have an existing health cover of about ₹5 lakh are porting to a higher sum insured of ₹10-15 lakh. While you must make it a point to follow all Covid protocols to avoid getting infected, here’s how you can financially shield yourself against Covid if you unfortunately fall sick.

 

Date extended for Covid-plans

In addition to taking toll on your health, Covid-19 infection can dent your savings as well.

Keeping this in mind, the insurance regulator, IRDAI has recently extended the validity for sale and renewal of short-term Covid specific health insurance policies – Corona Kavach and Corona Rakshak – till September 30, 2021. This was previously available up to March 31, 2021.

The insurance regulator in July 2020 had mandated that all general and standalone health insurers offer Corona Kavach health policy.

This (Corona Kavach) is an indemnity policy which pays for the hospitalisation of the insured affected due to Covid-19, provided he/she is hospitalised for a minimum period of 24 hours. It also offers cashless facility to its policyholders, provided hospitalisation is from the insurer’s list of network hospitals.

Hospitalisation cover includes expenses such as room rent, boarding, nursing, ICU, ambulance service up to ₹2,000, medical practitioner and consultant fees, operation theatres, PPE kit, gloves, etc.

It covers for home care treatment expenses as well, up to the sum insured (SI) for a maximum period of 14 days. All general and standalone health insurers offer this policy.

There are complaints that some hospitals are not granting cashless facility for treatment of Covid-19 despite policyholders being entitled for the same. The insurance regulator has recently clarified that wherever insurers have an arrangement with the hospitals for providing cashless facility, such hospitals are obligated to provide cashless service for all treatments including treatment for Covid-19. In the event of denial, policyholders can file a complaint with the insurer concerned.

Another plan introduced by IRDAI, but not mandatory to be offered by all insurers, is Corona Rakshak. It is a benefit policy, where the insurer will pay 100 per cent SI upon positive diagnosis and the policy shall terminate thereafter.

As both are standard policies, the coverages and exclusions across insurers will be the same, including the policy name. Both policies can be availed for a period of 105 days (3.5 months), 195 days (6.5 months) and 285 days (9.5 months) and can be renewed to ensure the benefit of the policy continues.

The minimum SI under both policies is ₹50,000; the maximum SI offered under Corona Kavach is ₹5 lakh and for Corona Rakshak ₹2.5 lakh. The minimum and maximum age of entry is 18 and 65 years respectively, and only single premium payment mode is allowed under both policies.

Regular health policies cover hospitalisation due to Corona virus among other diseases/accidents. At the beginning of the outbreak of the pandemic, there were problems over providing cover for associated costs such as personal protection equipment (PPE) kits.

These expenses formed part of consumables which were not usually covered by most insurers. Those who did cover, applied ‘proportionate deduction’ clause based on the type of hospital room availed.

In June last year, to reduce the burden of the policyholders and to standardise the claim settlement, IRDAI, ordered that medical expenses including cost of pharmacy, consumables, implants, medical devices and diagnostics to be covered as part of health policies without being subject to the ‘proportionate deduction’ clause. Covid-related expenses in the above-mentioned heads such as PPE kits will reap the benefit of this move.

Further, if you have a health policy which covers for out-patient (OPD) medical expenses – known as comprehensive cover – you can reimburse your Covid-19 related home treatment medical expenses too, if you are under home quarantine.

Making the choice

Your financial burden is likely to be reduced whether you have Covid-19 specific health covers or a comprehensive health cover. However, if you plan to sign up for one now, do note that all new health insurance policies come with a waiting period of 15 days, only after which your cover will kick in.

Covid specific plans as well as regular health cover have certain exclusions. Any unproven treatment will not be covered.

Coverage under both policies cease if the insured travels (outside the country) to a destination where India restricts travel to or the foreign country restricts entry of travellers from India.

So, if you are looking to buy a plan to protect against Covid, you can skip Corona Kavach if you have a regular health plan covering OPD expenses. Corona Rakshak can be useful if your regular plan does not cover OPD or if you are looking for additional cover. Since Rakshak is a benefit policy, this can come in handy to cover expenses for tests, scans, medicines, etc. for those who are home quarantined.

(This is a free article from the BusinessLine premium Portfolio segment. For more such content, please subscribe to The Hindu BusinessLine online.)

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Covid-19 claims register marginal decline: Insurers

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Medical costs and insurance claims for Covid-19 treatment seem to have declined in recent months, with treatment costs now largely standardised and better management of the infection.

According to insurers, the average claim amount is now at about ₹1 lakh for Covid-19 hospitalisation, compared to the previous ₹1.3 lakh to ₹2 lakh.

“Covid-19 claims have gone down from what it was initially. In the initial days, the average size went up to ₹2 lakh, but it has been consistently coming down… At the industry-level, it is in the range of ₹1 lakh. For us, the average size is ₹1.25 lakh to ₹1.3 lakh as our product has no constraints. We do all our underwriting at the sales time,” said Anurag Rastogi, President, Chief Actuary and Chief Underwriting Officer, HDFC Ergo General Insurance.

Rastogi attributed this to various reasons. “The government has intervened, different State governments have fixed that maximum ceiling and insurance companies have been working with hospitals to rationalise the costs. The hospital industry has been very supportive. The General Insurance Council has been working with hospital associations and IMA so that common customers are not inconvenienced,” he told BusinessLine.

Treatment costs

Sanjay Datta, Chief, Underwriting, Claims and Reinsurance, ICICI Lombard General Insurance, said overall, the per case treatment costs have remained the same or gone down slightly.

“The treatment has improved and not everyone who is getting Covid is getting hospitalised. More and more people with mild symptoms are isolating at home. Second, those who are going to the hospital are going at a stage when it is managed better. So, there are less cases of people going to ICUs or being put on ventilators. In terms of hospitalisation costs, doctors are now getting specific only tests done now,” he noted.

An industry expert, too, said that average cost now is at ₹1 lakh, or even marginally lower for Covid-19 hospitalisation. “This was at about ₹1.2 lakh to ₹1.3 lakh earlier,” he noted.

A second wave

The lower daily caseload has also brought some respite, but insurers say they are prepared for a possible second wave.

Sky-rocketing Covid-19 treatment costs, with bills for some patients reportedly touching ₹10 lakh, had proved to be a significant concern for patients and families and insurance companies. The General Insurance Council had even brought out an indicative list of treatment costs in an attempt to rationalise hospital charges.

According to industry sources, about ₹12,500 crore of Covid-related medical claims have been filed, of which, nearly ₹7,500 crore have been settled.

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How you can maximise your health insurance

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Enhancement of sum insured

If you already hold a health insurance policy, you can enhance your SI at the time of renewal. Accordingly, your premium outgo will also increase and widen the scope of coverage. But if you find the premium outgo to be high for the increase in SI, then you can consider a super top-up cover.

A super top-up plan is similar to a regular health cover where the policyholder gets covered for hospitalisation and other medical expenses. It is different only in terms of coverage initiation. That is, a super top-up will cover you once hospitalisation expenses exceed a certain limit known as ‘deductible’. Let’s understand this with an example. Assume you have a total cover for ₹3 lakh in your base health policy and you choose to purchase a ₹5 lakh super top-up product which has ₹3 lakh as deductible. Now, during a policy year, you make a first claim for ₹1 lakh. This gets covered in your base policy. Your second claim is for ₹2.5 lakh. Now, ₹2 lakh gets covered by your base plan and the balance ₹50,000 comes from your super top-up plan. The super top-up plan comes into use as you have crossed the remaining deductible limit of ₹2 lakh.

Key points

Though sum insured enhancement or super top-up plan is cost effective and widens the coverage and benefits, there are certain points to keep in mind. First, all the waiting periods – initial, pre-existing disease and disease specific waiting period will continue to apply on the increase SI.

Second, other conditions, including co-pay and deductible, if any, will also apply on the additional sum insured.

On the positive side, as super top-up plans are similar to a health plan, they comes with benefits such as cumulative bonus, restoration of SI, and wellness programme.

Sum insured as reward

Most health insurance policies in the market offer built-in options to increase or restore your SI every year without any additional premium. Under this feature (known as restoration feature), the insurer fully reinstates the original SI once the entire health cover is used up during the policy year. Some insurers reinstate original SI even after partial exhaustion of (original) SI.

No-claim bonus or NCB is another feature through which the insurer increases your SI without any increase in your premium . However, the increase in SI comes with a limit, say, 10 or 20 per cent increase in base SI every year, usually up to 100 per cent of SI, if there is no claim filed by the policyholder.

You can even opt for the NCB rider over and above the in-built NCB in the policy for additional costs.

Your choice

Though insurers reward you with an increase in SI, it has its own limitations in terms of reinstatement of SI and having a claim-free year mandatory for NCB. The pace of increase may be slower as well. Therefore, between additional increase and a super top-up plan, you can choose what works for you, based on the additional premium you have to pay and the coverage and other benefits.

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