1 month ago
Monsoon respiratory infections: Health insurance coverage and claim denials
During the monsoon season, respiratory infections like influenza, bronchitis, and pneumonia become more common.
Health insurance policies usually cover hospitalisation expenses for severe infections, but not for mild cases treated at home or through outpatient consultations.
However, if you have additional benefits like OPD cover or domiciliary treatment, you might get coverage for non-hospitalised treatments.
It's important to check your policy before making a claim to avoid surprises.
Preventive health check-ups can help identify underlying respiratory risks, and it's crucial to disclose any pre-existing conditions when buying a policy to avoid claim denials.
Standard health insurance policies cover hospitalisation expenses for severe respiratory infections.
Mild infections treated at home or through outpatient consultations may not qualify for claims.
Additional benefits like OPD cover or domiciliary treatment can provide coverage for non-hospitalised treatments.
Preventive health check-ups can help identify underlying respiratory risks.
Claims may be denied due to inadequate documentation, non-disclosure of pre-existing conditions, or waiting periods.
- Who
- Policyholders with health insurance
- What
- Coverage and claim denials for respiratory infections during monsoon
- Where
- India
- When
- During the monsoon season
- Why
- To understand what is covered and what may lead to claim denials
Insurance Coverage
Claim Denials
Hospitalisation Requirement
Insurance Coverage
Standard health insurance policies cover hospitalisation expenses for severe respiratory infections like pneumonia or bronchitis.
Claim Denials
Mild respiratory infections treated at home or through outpatient consultations may not qualify for claims.
Additional Benefits
Insurance Coverage
Policyholders with OPD cover or domiciliary treatment benefits may have coverage for non-hospitalised treatments.
Claim Denials
Claims may be denied if the policy does not include these additional benefits or if documentation is inadequate.
Preventive Health Check-ups
Insurance Coverage
Comprehensive health insurance plans often include preventive health check-ups to identify underlying respiratory risks.
Claim Denials
Claims may be denied if pre-existing conditions like asthma or COPD are not disclosed at the time of purchasing the policy.
Key facts
- Key Trigger for Claims
- Hospitalisation (minimum 24 consecutive hours of in-patient treatment)
- OPD Rider Benefits
- Covers doctor consultations, prescribed medicines, and diagnostic tests without hospitalisation
- Domiciliary Hospitalisation
- Covers home treatment when hospitalisation is required but not possible
- Preventive Health Check-ups
- Offered after a claim-free year in comprehensive health insurance plans
- Common Reasons for Claim Denials
- Inadequate documentation, non-disclosure of pre-existing conditions, and waiting periods
Quotes
Dr Amol Sawai
Senior Vice President and National Product Head – Accident & Health Underwriting at Liberty General Insurance
“Indemnity‑based health insurance policies are designed to cover expenses arising from hospitalisation, typically defined as a minimum of 24 consecutive hours of in‑patient treatment. So, a mild cold or seasonal flu treated with over‑the‑counter medication at home would not trigger a claim.”
livemint.com
Sources
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