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It is not the first time that hospitals and non-life insurers have locked horns over exorbitant medical bills charged from patients. During the first wave of coronavirus, the high cost of hospitalisation added to the financial burden of families and now with the second wave hitting the country, reports of a tussle between insurers and hospitals have started resurfacing. Here we take a look at things which your health insurance policy may not cover either because of exclusions in the policy or due to overcharging by hospitals:

Personal Protective Equipment (PPE)

PPEs have again become a significant cost of hospital bills, which insurers are disallowing if it is in excess of the specified limit. Last year in July, when the high cost of PPEs became a cause of concern for many, General Insurance Council (GIC), an umbrella body of non-life insurers, prepared a rate chart for COVID-19 treatment after taking into account rates published by various state governments. The suggested rates were broadly based on the schedule of rates that were suggested by the Niti Aayog panel. Under the new proposed rates, the partner hospitals can charge between Rs 1,200 and Rs 2,000 for PPE depending upon the severity of the sickness. But insurers say PPE kits have once again become a significant cost of hospital bills, which they saw going down in between. With hospitals charging as high as Rs 10,000 for PPEs it has again become a point of tussle between the two.

Cashless treatment

Insurance companies have brought to notice that many hospitals have started refusing cashless claims to patients leading to a rise in hospital bills. Dr Bhabatosh Mishra, Director- Claims, Underwriting & Product, Max Bupa Health Insurance said: “We have got tariff agreement with network hospitals for cashless treatment of Covid-19. But we have seen that hospitals are pushing for claim settlement on reimbursement basis leading to rising in hospital bills.”

Higher antibiotics

Insurers are also complaining that there has been high usage of antibiotics for the treatment of Covid-19 compared to the first wave. Moreover, there are complaints of shortage and overcharging resulting in a jump in the hospital bills.  Bhaskar Nerurkar, Head – Health Claims, Bajaj Allianz General Insurance, said, “Currently, with the increase in cases, the information we have received from the hospitals is that they are facing limitation of bed availability. An additional challenge faced by hospitals is that some of their regular staff are also infected. Hence the communication on the claims front is facing some challenges. Insurance companies typically pay for medicines on MRP basis and hence fluctuations in prices don’t affect insurers.”

Non-payable items

According to the Insurance Regulatory and Development Authority of India (IRDAI), there is a standard list of 199 items that are non-payable and therefore not paid at the time of settling a claim. For example, other than PPE there are toiletries and cosmetics items such as slings, razors, cradle charges, among others which are part of the non-payable items. Similarly, nebuliser kits, steam inhalers, thermometers, private nurses and attendant charges fall under the non-payable items and are not covered under your policy.

It is always advisable to create a health fund, where you save regularly and be prepared to pay the part of the hospital bill which is not reimbursed by your insurer.