Coronavirus is not out of the woods but and the threat of the third wave is carrying out the rounds. While sustaining all Covid-19 protocols is the will need of the hour, one also requires to assure there is sufficient well being insurance coverage cover to fall back upon in occasions of will need. But, of late, there have been apprehensions about the Covid-19 connected insurance coverage claims not getting accepted by insurers or claims receiving delayed or partially paid to the policyholders.
Health insurance coverage providers have received a total of 23.06 lakh claims worth Rs 29,341 crore as on August 6, 2021, according to figures compiled by the General Insurance Council. However, insurance coverage firms have settled Rs 17,813 crore involving 18.99 lakh claims so far.
In order to clear the air about insurance coverage claims and the mechanism for the policyholders to raise a grievance, FE Online in an e-mail interview sought the answers about settlement of claims from Abhishek Tripathi, Managing Partner, Sarthak Advocates & Solicitors. Excerpts:
What is the course of action if a claim is denied? What is the approach and timeline ahead of lodging a complaint with the insurer, Ombudsman and customer court?
If the claim is denied, the policyholder should inquire about the factors. Often rejection on the grounds such as inadequate bills or documents can be resolved by submitting the relevant documents.
Against the rejection of a claim, the initial recourse is to the grievance committee of the insurer. Although no timeline has been specified for the exact same, it will be excellent to avail this remedy inside 3 years of rejection of the claim to stay clear of the claim becoming time barred beneath laws of limitation.
Against the grievance committee’s selection, the Ombudsman can be approached. The communication from the insurer need to specify the specifics of the Ombudsman to be approached. Ombudsman should be approached inside one year from the date of rejection of the complaint by the insurer’s grievance committee.
If the customer is dissatisfied with the Ombudsman’s determination, (s)he can strategy the customer courts inside 2 (two) years.
It is pertinent to note that IRDAI has established an on the net complaints registering method named the Integrated Grievance Management System (IGMS) exactly where the kind with the complaint can be filled and submitted. Complaints submitted on IGMS are forwarded to the insurer as effectively as IRDAI. IRDAI monitors the disposal of the complaint submitted on IGMS portal.
In case a claim is partially settled, need to one accept and later on strategy court and so on to settle complete dues?
It is prevalent for the insurance coverage providers to seek a letter or undertaking from the insured releasing the insurer of any additional claim. It is advisable to stay clear of providing such undertakings, and exactly where such undertakings are forced, a protest is lodged instantly with the insurer. Partially settled claims can, hence, be accepted beneath protest, and the courts may possibly be approached for the settlement of the remaining claim. Courts may possibly have to be convinced, in such situations, that the release, if any, executed by the customer was executed beneath duress and need to be disregarded.
What is the basic trend in terms of Covid-19 claims getting settled by the insurance coverage providers?
Claim settlement turnaround time has been decreased by most insurers following IRDAI’s directive, even so, some issues about settlement stay. According to the business information, as on July 19, 2021, of the total reported claims of Rs 27,640 crore, claims worth Rs 16,396 crore had been settled. Settlement amounts ranged involving 55 per cent and 65 per cent of the claim.
In the initial Covid wave (up to February 22, 2021), insurers reported claims worth Rs 13,736 crore, of which claims worth Rs 7,125 had been settled.
In the second wave – from February 23 to July 19, 2021 – of total well being insurance coverage claims of Rs 13,905 crore, claims worth Rs 9,271 crore had been settled.
As per IRDAI, inside how a lot of days need to insurers make reimbursement to the policyholder?
According to the suggestions issued by the IRDAI, insurers are essential to settle or reject the claim, as the case may possibly be, inside 30 days from the date of receipt of the last important document. Where investigation is warranted, the insurer is essential to full the investigation inside 30 days and accept or reject the claim inside 45 days of receipt of the last important document. If there’s a delay in the payment of the claim, the insurer is essential to interest at a price 2% above the bank price, from the date the reimbursement is payable.