It’s a pandemic situation and hospitals are working to their full capacity all over the world. The number of health claims are rising every day. While the insurance regulator (IRDAI) has asked insurers to expedite claims settlement for COVID-19 claims, there have been some instances of the claims being rejected.
Insurance Regulatory and Development Authority of India (IRDAI) will seek detailed report on Insurance claim rejection in case policyholders complains as suggested in their guidelines to the Insurer. They will have to explain the reasons why the claim has been rejected. The insurer has been asked to be sensitive to the customers in these times.
In many instances the cashless claim is rejected and the customer is asked to pay the hospital bills which are amounting to an average of 2-3 lacs.
Steps to take if the Cashless Claim is Rejected in Hospital
- Submit the documents for reimbursement: You need to submit all documents to the insurance company to apply for reimbursement. This may be a cumbersome process where you need to have all prescriptions, tests conducted, medicines bills and other miscellaneous bills arranged in a proper sequence for the insurance company to pay the bills. The reimbursement form needs to be filled. If submitted properly the insurance company will settle the bill in 30 days.
- Answer all query: If the company raises some requirement in your case then the same needs to be arranged from the hospital and submitted to the company. They would then settle the claim
- Write to the grievance cell: If they reject the claim, you need to raise the concern with the insurer grievance cell and seek clarifications. If they give you valid reasons and the same is validated by you, the claim will not be payable. But if the reason is not valid, you have to argue with the officer to get your claim. This requires technical assistance to answer in the language the officer understands and can be challenging at times.
- Write/ Call to IRDA: You can also raise the concern to IRDA if you feel that you have been cheated by your insurer. Please note that IRDA only facilitates the grievance and do not directly interact with the customer. They send your complaint to insurer and get the response from Insurer. They do not call customers. So, if you get any call from IRDA note that there is some fraudulent activity.
- File the case with the Ombudsman: The ombudsman helps in mediating the claim and require proper documentation of the compliant. You need to submit the complete set of documents for the Ombudsman to accept your complaint and schedule a hearing on your case. Ombudsman requires the customer presence on the date of hearing to decide on the case
- File the case in consumer court: You may also consider consumer court which again will require complete documentation to be submitted to get the hearing dates. Here your lawyer can attend the hearing and your presence may not be required in all hearings
Insurance Samadhan has also stepped up to help claim rejection in case of Covid-19 claim rejection, you may seek waiver of the registration charge of Rs 500 in such cases. We shall work on your case and do all the documentation and if required will go through all the steps to help you get your genuine claim amount.
In Case if you are still facing some real issues regarding Covid-19 Hospitalization Reach us to below given details we'll help you out from this.
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