Insurers seek re-pricing of Corona Kavach, Corona Rakshak policies

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Worried by rising claims and low premium, insurers have approached the insurance regulator IRDAI for a re-pricing of the Corona Kavach and Corona Rakshak policies.

Insurers point out that these low ticket policies were expected to be for a short duration, but with the pandemic continuing, they are turning out to be expensive propositions for them and hitting their balance sheets.

 

“The industry as a whole has asked for repricing of Corona Kavach and Corona Rakshak. We priced it around June 2020, and the actual peak has been five to 10 times of the expectation. These products are a guaranteed loss of money,” said a source privy to the development.

Sources said general insurers discussed the issue with IRDAI recently and shared data on losses.

 

“Insurers too have to report to their shareholders. These schemes were supposed to be for a short duration and no one had thought that Covid cases and claims would rise to such an extent,” noted another insurer.

Covid-specific covers

The Corona Kavach and Corona Rakshak policies were launched last year based on IRDAI guidelines by all insurers to provide Covid-specific cover to customers.

 

Corona Kavach is a family health insurance policy for Covid-19 with sum insured between ₹50,000 and ₹5 lakh available with a term of three and a half months, six and half months and nine and half months. Premiums are as low as ₹150 in some cases.

Corona Rakshak is a defined benefit policy with a sum insured between ₹50,000 and ₹2.5 lakh.

 

Comprehensive cover

Many insurers are now advising customers to move to Aarogya Sanjeevani, which is the standard health policy, which would provide more comprehensive health cover. Some insurers said that customers, too are preferring to shift to a full-fledged health cover.

 

“One of the objectives, when these policies were launched, was that they would educate customers about the benefits of health insurance and they would eventually migrate to full fledged covers,” noted an insurer.

A recent note by ICICI Securities said that industry-wide Covid claims till May 14, 2021 was 1.5 million in terms of number and $3.1 billion in value compared to 11.1 million in numbers and $2.1 billion in value in 2020-21.

 

“Our channel checks indicate that industry losses are higher on Covid-specific polices (Corona Kavach and Corona Rakshak),” it said.

The general insurance industry has over ₹24,000 crore of Covid related claims to date from the beginning of the pandemic.

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Reflecting the wide spread of Covid, insurers report a surge in claims from rural regions, too

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Health insurers are reporting a flood of Covid-related claims from across the country, including rural regions, reflecting the spread of the pandemic.

Rapid rise

Till last month, Covid claims had been mainly from urban areas of Delhi, Maharashtra, Uttar Pradhesh, Chhattisgarh, and Bihar as also some from Tamil Nadu and Karnataka.

“However, we now see a surge in claims from rural areas, too, in line with the rapid surge of the Covid-19 pandemic across regions,” Sanjay Datta, Chief-Underwriting, Claims and Reinsurance, ICICI Lombard GIC, told BusinessLine.

Health insurers have been seeing a jump in the cashless treatment claims relating to Covid-19 cases, Datta said. The government and the Insurance Regulatory and Development Authority of India recently told all hospitals not to deny cashless treatment for those eligible under their insurance plan. “Going by the current trend of rising cases, we need to wait and see how the claims scenario will be during this fiscal,” Datta said.

“We have paid Covid-19 claims to 14,500 customers. In 2020, it was around 10,000 in eight months, whereas in 2021, we have witnessed 4,500 claims in just three months,” said Bhabatosh Mishra, Director Underwriting, Products and Claims, Max Bupa.

The average claim size is at about ₹1.4 lakh but there are instances of claims going as high as ₹30 lakh depending on the insurance policy. The industry estimates the total Covid-19 claims payout from the start of the pandemic at ₹15,000 crore.

Demand for cover up

The demand for health insurance, in general, and Covid-cover, in particular, has been going up again. “The second wave of Covid is spreading at a faster rate, which has led to a significant increase in the demand for health insurance policies,” said the top executive of a private health insurer.

According to Datta, many of those who had taken Covid-specific standard cover under ‘Corona Kavach’ have been renewing it, even as fresh demand from new customers is emerging. The Insurance Regulatory and Development Authority of India recently extended the deadline for sale/renewal of standard Covid-specific policies by six more months in view of the resurgence of the pandemic.

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‘Be more transparent in health insurance claims settlement’

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Insurance sector regulator Irdai has asked all insurers to be more transparent in their health insurance claim settlement process and apprise the policyholders of reasons in case of denial of claims filed.

It it essential that all insurers establish procedures to let policyholders get clear and transparent communication at various stages of claim process, Irdai said in a circular. “All the insurers shall ensure putting in place systems to enable policyholders track the status of cashless requests/claims filed with the insurer/TPA through the website/portal/app or any other authorised electronic means on an ongoing basis,” said the regulator.

The circular on ‘Health Insurance Claims Settlement’ is addressed to life, general and standalone health insurance companies including the third party administrators (TPAs).

It has said insurers should ensure that policyholders are provided granular details of the payments, amounts disallowed and the reasons for the amount disallowed, as per the regulatory norms.

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How health cover cushioned impact of Covid

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Health insurance has come a long way in the last one year in providing succour to the general public affected by the Covid-19 crisis.

Even as coronavirus completes one year of unleashing physical, psychological and economic turmoil on almost all sections of the society, the response from the regulator, industry and public to the first-ever major health crisis in the last one century, stands out quite prominently.

In the last one year, product innovation and standardisation have been driven by the insurance regulator, Insurance Regulatory and Development Authority of India (IRDAI), whose policy framework was met with an enthusiastic response from industry players.

The IRDAI has also played a pivotal role in simplifying complexities in health insurance policies, bringing in transparency to provide clarity to policyholders.

Standard Covid basic products

In the face of the Covid-19 challenge, the regulator rose to the occasion by introducing standard Covid basic products, ‘Corona Kavach’ and ‘Corona Rakshak’, to be offered by non-life and life insurers mandatorily for nine-and-a-half months.

All general and standalone health insurers began offering the products from July 10, 2020. In the backdrop of Covid cases surging between March and September 2020, the introduction of standard covers made a key difference to general public, according to industry experts. As the focus shifted gradually from hospitalisation to home care treatment, a provision to cover home care treatment costs under Covid-specific insurance products was brought in.

The Corona Kavach policy underwent regular modifications in the backdrop of changing ground realities and requirements of patients, and was made to cover some associated costs, including expenditure for personal protective equipment.

The IRDAI Chairman, Subhash C Khuntia, underscored that insurance companies must come to the rescue of policyholders and cater to the changing needs of customers in difficult times. The Covid-specific insurance products are a case in point, and reflect the adaptability of the regulator as well industry players. Corona Kavach finally turned out to be the right product that is aptly designed to cover all specific aspects associated with Covid-19, such as testing and home treatment costs.

The systematisation/standardisation of treatment costs were also ensured by the General Insurance Council (GIC), which brought out an indicative list of treatment costs. This had a positive impact on all Covid-related claims in the last one year.

Covid-19 hospitalisation rates have been arrived at by the council after taking into account the rates fixed by different State governments and after consultations with doctors. Similarly, the basic standard health cover product, ‘Arogya Sanjeevani’, has made good inroads. The standard health cover policy, offered by general and health insurers, provides a maximum cover of ₹5 lakh.

Going forward, Arogya Sanjeevani can provide a further boost to the health insurance portfolio in the post-Covid era.

A big shift

The Covid-19 outbreak and the need for health insurance can prove to be a game-changer for the industry in the days to come.

Innovative products and new service offerings such as telemedicine are likely to pick up, opening up new avenues in health cover, too. Digital technologies and their increased use, both by insurers and customers, are also expected.

There has also been an increase in demand for health insurance by consumers as they have become more health-conscious. The increase in demand has been fuelled to a significant extent by the younger generation, say industry sources.

As per the data available with insurers, millennials were the top buyers of the Corona Kavach plan, as over 40 per cent of the buyers are in the age group of 18-30 years.

As the treatment costs are high in private hospitals, data show that a good number of policyholders had opted for the higher side of the sum insured of ₹2 lakh to ₹5 lakh.

While the Covid threat is expected to pass over a period of time, with vaccination as well as preventive protocols by the larger public, the interest in health insurance is here to stay.

According to Sanjay Datta, Chief-Underwriting, Claims and Reinsurance, ICICI Lombard GIC, while Covid-specific policies were short-term policies, they created greater awareness on the need for long-term and regular health insurance.

“Overall, they have created large-scale awareness among the general public,” he told BusinessLine. As per industry estimates, insurance penetration in the country was at 3.78 per cent in FY20, which is low compared to the global average of 7.23 per cent.

Of this, the non-life segment penetration amounts to only 0.97 per cent. This is expected to expand further.

The final impact

What will be the final impact of coronavirus on the bottom line of insurers? It may take more time to get an answer for this question.

According to the CEO of a major non-life insurance company, an understanding of the net impact of Covid on the business of general insurers, may differ from company to company.

“As of now, we can say that health insurance business has certainly got a boost and it has overtaken motor segment. But the real picture will only come out with full-year numbers,” he added.

The lessons learnt in response to Covid can also go a long way in preparing for future perils to public health and designing viable and efficacious products.

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Is mental illness cover worth the money?

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While all health insurance companies were mandatorily required to cover mental ailments from 1 October 2020, the experience of those suffering from mental conditions and having an insurance cover, is different. Recently, a reader wrote to us saying that public sector health insurers still have mental illnesses under exclusion list and are not offering coverage.

When we checked, we found he was right. Websites of insurers – United India Insurance Company and the New India Assurance Company, had psychiatric and psychosomatic disorders in the exclusion list.

The IRDAI’s mandate to treat mental illnesses at par with physical ailments and remove it from exclusions, has not been implemented by all insurers.

If you are concerned about mental ailments (including depression, bipolar disorder, schizophrenia, anxiety disorders, psychotic disorder and others) and related expenses, do your homework before you sign up for a health insurance policy – go through the policy document and ensure that it covers hospitalisation due to psychological disorders and mental illnesses.

One thing to note is that treatment for mental ailments in most cases is offered as OPD (Out-Patient Department) consultation. Given that most health insurance plans do not cover OPD expenses, and require minimum 24 hours hospitalisation, claims on consultation in OPD, gets rejected.

Cover for mental ailments

To see if at least the private insurers have incorporated coverage for mental ailments in their health policies, we checked a few big players. The policy document for HDFC ERGO’s my:health Suraksha specifically mentions coverage for hospitalisation expenses (it is silent on cover for OPD consultations) to treat mental ailments.

In ICICI Lombard’s Complete Health Insurance plan, mental illness in not in the exclusion list; the policy covers OPD expenses, for additional premium. In Star Health’s Medi Classic Insurance Policy, if the insured person is diagnosed with psychiatric or psychosomatic disorder for the first time and hospitalized for a minimum period of five consecutive days, then the company will pay hospitalization expenses up to the sum insured.

In Manipal Cigna Health Insurance’s ProHealth plan, there is cover for expenses on mental ailments; the policy brochure, though, does not delve into details.

If you are looking for insurance policies that give OPD covers, so that you can claim for OPD treatments and consultation for mental illness, then ICICI Lombard’s Complete Health Insurance plan and Max Bupa’s GoActive plan/Health Premia plan can be considered.

While GoActive covers OPD consultations (with cap on number of consultations), HealthPremia covers OPD treatment (with cap on claim at ₹50,000). Digit’s health insurance plans provides cover for mental illnesses. If the OPD add-on is opted for, then consultations and therapies under OPD are covered too. However, note that this cover comes with co-pay (for first two years) requirement and the maximum benefit one can avail is ₹ 5,000.

Are OPD covers worth it?

OPD covers, when offered either as in-built in the policy or sold as separate riders, are expensive as insurers are certain that the person who buys the cover is going to make claims on it, and there are limited means to cross-check the medical bills they would provide.

So, for the amount of sum insured (SI) they offer, the premium would almost be 70-75%; with section 80D benefit under the Income Tax Act, the asking price will be 50% of the benefit given.

With OPD covers, you also need to note that many a times, the claim will be settled by reimbursement and cashless benefit will not be given. You would also have to note that OPD policies mostly do not cover cosmetic treatments and expenses on vitamins and tonics unless forming part of treatment for injury or disease and expenses on inoculation or vaccination (except for post–bite treatment and for medical treatment for therapeutic reasons).

Keep some free cash with you always for medical emergencies. Even if you have health insurance with OPD cover for mental ailments, the sum insured under the OPD cover may not suffice.

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Benefit illustration must in health insurance plans: IRDAI

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A clear benefit illustration should be made an integral part of sales literature of health insurance products issued on a floater basis, according to the insurance regulator.

In a circular on benefit illustration in health cover, the Insurance Regulatory and Development Authority of India (IRDAI) has directed insurers to provide benefit illustration to customers in six age groups beginning from 20 or lower age bracket to over and above 66 years.

This should be attached to every health insurance product’s customer information sheet, the regulator said.

The insurers should also provide a customised benefit illustration in a prescribed format to help them make out the difference between different plans.

All insurers must adopt these norms on or before April 1, 2021, the circular said.

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₹1-crore health plan is a sensible idea

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Until a few years ago there were no options to get a sum insured (SI) of over ₹5 lakh in health insurance in India. Today, there are a handful of insurers offering ₹1-crore health cover for self and family. However, is there a need for ₹1-crore health insurance? Also, will one get benefits such as treatment outside India and a deluxe room while in hospital?

Before we delve deeper into this topic, note that health insurance plans are indemnity covers that pay for the medical bill on hospitalisation up to the sum insured. They are not like the critical illness insurance plans that pay the full amount of SI at the first instance of hospitalisation irrespective of the hospital bill.

There are still reasons for you to go for health insurances plans and not critical illness plans if you want to cover hospitalisation expenses and ₹1-crore health cover makes more sense.

 

The logic

In regular health insurance plans, you can make claims on the policy as long as there is SI left in the plan; the cover is renewable life-long. In contrast, the critical illness (CI) plans are one-time covers; once claimed, the policy pays the full value of cover and terminates; you can’t renew the policy again the next year. But most critical illnesses recur after a few years and by that time if you had exhausted all the money form the first claim, you will be without any back-up to pay for hospitalisation. So, it is recommended that you buy a health insurance policy that by regulation is renewable life-long and can take care of the recurring medical expenses throughout your life time.

The next question is how much cover? Treatment cost of chronic ailments, including cancer, run into lakhs of rupees. Rather than guessing how much cover you would need, you can take a ₹1 crore cover at the age of 35-40 years for your peace of mind.

As you age, if you find the premium expensive, you can reduce the SI by a few lakhs, but you would still continue to enjoy a large cover without fresh underwriting. On the other hand, if you had say ₹5-10 lakh cover and in your mid-40s want to increase the SI to say ₹25-30 lakh, there will be fresh underwriting and waiting period, and it can’t be easily done.

Currently, the ₹1-crore health plans are not expensive at all. Check this: For a 35-year-old male, in case of Max Bupa, the annual premium for ₹25 lakh SI plan is ₹14,626 and the cost of ₹1 crore plan is a lower at ₹10,992. Similarly, in case of Aditya Birla Capital, while the annual premium for ₹25 lakh SI is ₹11,245, the premium for ₹1 crore cover is ₹9,557.

Insurers price the ₹1-crore plans cheaper, assuming there are rare chances of claims over ₹25 lakh.

One thing to note that both the above ₹1-crore plans are combo plans – of base policy of ₹5 lakh and a super top-up of ₹95 lakh. The super top-up will get triggered the moment the base policy SI is exhausted. Since both the base and super top-up covers will be with the same insurer, there will be hassle-free claims process.

For a single plan of ₹1 crore, you can go for Care Health Insurance’s Care Advantage, but it is more expensive than both plans mentioned above.

A ‘no-frills’ plan

If you think that the ₹1-crore health plans will come with benefits of international coverage and high-end deluxe rooms in hospitals, sorry. There are no added frills in the ₹1-crore plans. These plans have the bare minimum necessities for someone looking for a hospitalisation cover. That said, they cover single private room accommodation, come with NCB, and cover all-day care procedures as regular plans and pre/post-hospitalisation for 30 and 60 days respectively, as usual. In Care Health’s Care Advantage plan for ₹1 crore, however, all category rooms, including suites are covered.

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How ‘restoration benefit’ in health insurance works

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Most health insurance policies in the market offer built-in back-up plans for policyholders in the form of ‘restoration’ benefit. In this feature, the insurer fully reinstates the original sum insured (SI) once it is exhausted. This means, in a floater policy, if any other family member gets hospitalised even after the entire sum insured (SI) is used up in a policy year, there will still be a cover available to the extent of the full SI. This reinstatement of health cover is welcome, especially if your original cover is small. Restoration feature is also termed as refill, reset or reload depending on the insurer.

However, restoration benefits come with caveats and limitations. Here is what you should know.

The basics

While health insurers offer to reinstate your original SI, the restoration process varies with insurers. Some policies such as Manipal Cigna’s ProHealth policy, Activ Assure Diamond policy from Aditya Birla Health, ICICI Lombard’s iHealth Plus restore your original SI only after the existing cover is exhausted.

Let’s understand this concept with an example. Joe has ₹5 lakh as health cover and, on his first claim, this amount gets utilised. A few months later, he gets hospitalised for another illness, and his second claim is for ₹2 lakh. Given that his original SI is exhausted, his restored SI will be ₹5 lakh and the insurer will settle his claim (of ₹2 lakh).

Now, let’s take another case. Joe’s first claim is for ₹4 lakh; the balance SI will be ₹1 lakh. He makes a second claim for ₹2 lakh. The insurer will cover only ₹1 lakh and Joe will have to settle the balance from his pocket. The ‘restore’ benefit will not be triggered as Joe has not exhausted his SI completely. However, if Joe makes a third claim in a year, he will have ₹5 lakh as his SI.

There are health covers in the market such as Optima Restore from HDFC Ergo Health, Max Bupa’s Go Active policy and Lifeline by Royal Sundaram General Insurance that offer to reinstate the original SI even when the SI is partially exhausted.

For instance, let’s assume Joe has a health policy of ₹5 lakh and he makes a claim for ₹3 lakh (first claim). The insurer settles the claim and Joe’s SI balance is ₹2 lakh. His ‘restore’ benefit is triggered (available only for subsequent claims) and his SI balance for the year will be ₹7 lakh (existing balance of ₹2 lakh and SI restored is ₹5 lakh). What must be kept in mind is that a single claim in a policy year cannot exceed base SI. Which means, if Joe makes a second claim for ₹6 lakh, the insurer will pay ₹5 lakh only and the balance ₹2 lakh SI will be available for subsequent claims.

Note that, while most policies come with ‘restore’ benefit, it may be not available across all variants of a particular policy. For instance, in ICICI Lombard’s iHealth Plus, the ‘reset’ benefit is available from SI of ₹3 lakh and above only. Similarly, in Digit Insurance’s health plan, the ‘restore’ benefit is available for comfort variant of the plan only.

What’s the catch?

Since most insurers offer ‘restore’ or ‘refill’ benefit as an in-built feature in the policies, there are certain points that you as a policyholder should keep in mind.

One, ‘restore’ benefit is usually available only once during a policy year when insurers refill 100 per cent of the base SI. But there are policies in the market such as Pro Health policy (Manipal Cigna), Max Bupa’s ReAssure plan and Star Health’s Family Health Optima plan (SI is restored three times a year), that offer ‘restore’ benefit multiple times. Insurers also offer unlimited ‘restore’ benefits as a rider, like in Religare Health insurance’s Care plan and Activ Assure Diamond plan (Aditya Birla Health).

Two, as a norm, the ‘restored’ SI will be available only for subsequent claims made by the policyholder. That is, the ‘restore’ benefit will not be applicable on the first claim in the policy year. Also, most policies do not offer the ‘reinstated’ SI for the same illness for which you had made the claim in a policy year. However, some policies in the market such as ReAssure (Max Bupa) do cover for the same illness subsequently.

Three, your ‘restoration’ SI will not be considered for no claim bonus (a reward that policyholders receive from the insurer for staying healthy and not making any claim on the policy in a year) calculation.

Lastly, the SI reinstated during the policy year, if unutilised, will expire and cannot be carried forward to next year or at the time of renewal of policy.

Remember that your reinstated SI can be utilised only sequentially, that is, after exhausting the original SI, accumulated no-claim bonus (NCB) SI, additional or super NCB (if any opted), and additional SI through booster benefit (if any opted).

Our take

SI restoration benefit is offered by most health insurers as part of the basic cover. While this benefit can compensate if you are under-insured, relying on reinstated SI to make up for the gap is not advisable. Also, you need to understand the workings and applicability of this feature and choose a SI, accordingly, based on your need.

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