34% increase in health insurance complaints
The Insurance Lokpal office in Mumbai has released some figures. There has been an increase of about 34 percent in health insurance complaints of policyholders in 2021-22 as compared to the previous year. This insurance center handled 2,298 health insurance complaints in 2019-20 and 2,448 in 2020-21, but according to the annual report for 2021-22, this figure has increased to 3,276 in 2021-22. This report does not tell the separation of Kovid-19 and non-Covid-19 claims.
Many complaints came during the time of Corona
The increase in these complaints occurred at a time when the delta of Mumbai and the country Corona and omicron Was experiencing waves of variants. Mumbai and Goa Insurance Ombudsman Bharatkumar Pandya at a recently held media conference said that most of the COVID-19 related complaints are related to partial settlement of hospitalization claims. Then there are cases where claims were rejected outright on the ground that the patient did not require hospitalization.
What is policy contract
Pandya says that, “We pass judgment after examining each case individually. In general, however, the insurer has to go through the terms and conditions of the policy and these tariffs do not form a part of the policy documents. In some cases, the rate cards set by the government were not applicable to the insured patients. Hospitals’ view that the COVID-19 tariff imposed by the government was only for uninsured patients resulted in a standoff between hospitals and insurers. This put the policyholder patients in trouble. The reference rates published by the GI Council were also indicative and were not mandatory for insurers to follow.
What are the terms of the policy
Disputes between policyholders and insurers have a waiting period. Most health policies do not cover the cost of cataract or hernia treatment in the first policy year. The Mumbai Center’s report identifies resiliency clauses in health insurance contracts, which reduce reimbursement, as a major cause of disputes. According to the report, the mention of customary and reasonability clauses with respect to hospital treatment is both inappropriate and counter-intuitive. Why will the insurer not take up the issue of ‘over-charging’ with the hospital and pay the insured?
Submit your complaint here
Rejection of an insurance claim by your insurance company may not be the final decision. You can lodge a complaint with the IRDAI and Insurance Ombudsman offices in your city. The Lokpal offices handle complaints involving claims up to Rs 30 lakh. After the complaint, the Insurance Ombudsman passes the order after examining the arguments of both the parties. If you are not satisfied with this decision, you are free to approach the consumer courts. This order is binding on the insurance companies.