Covid-19 has taken our country and the entire world by surprise and has emerged as a never imagined black swan event. It has instilled a sense of fear in every individual and has not only challenged but changed our lifestyle completely.
Further with the number of COVID cases being on the rise, day on day since the advent of the COVID pandemic since March 2020, the cases are being diverted to the Private care with caveats on rational costing.
The medical, para-medical fraternity and hospitals are at the forefront in providing medical care to people affected from Covid-19. We insurers are helping our policyholders manage their scarce financial resources by expediently processing their Covid-19 insurance claims. Unfortunately, Covid-19 is a new illness with no established protocols and standardized treatment costs. This may at times result in an insurance company raising questions on the amounts spent on the Covid-19 treatment. This creates a huge uncertainty in the minds of unsuspecting covid-19 patients.
In order to allay the fears of all insurance policyholders and to bring complete clarity and transparency in the treatment of Covid-19 insurance claims, the General Insurance Council, in discussion with expert medical professionals employed by member insurance companies, has brought about a Schedule of rates for Covid-19 claims being filed with its member insurance companies. Insurance companies shall be guided by the Treatment Protocols prescribed by ICMR. These rates are broadly based on the schedule of rates suggested for covid-19 treatment by NitiAyog Panel.
These rates will be applicable to both cashless and reimbursement Covid-19 claims in States/Union territories/Cities where any Government Authority has not published standard charges for Covid-19 treatment. Wherever, Covid-19 treatment charges have been published by any Government Authority, those charges shall be applicable to insurance claims with member companies. These charges shall be reviewed by Council every month to ensure that these represent Usual, Customary and Reasonable charges prevalent in the Indian market at that time and do not cause any hardship to insurance customers. The settlement under the Covid-19 insurance claims shall be subject to the limits and terms of the policy of respective insurer.
This document hence proposes to create a consensus on the billing pattern for COVID patients, on a Per Diem Bases, rather than line item billing, based on the following criteria –
a. Type of stay & treatment, during hospitalization
b. City/District of Hospital
c. Type of Hospital
1. The Proposed Cost per day as a ceiling for the various types of stay in hospitals are as follows –
| Category of Hospitals | Moderate Sickness (ISOLATION BEDS including supportive care & oxygen) | Severe Sickness (ICU without need for ventilator care) | Very Severe Sickness (ICU with ventilator care) |
|---|
| NABH Accredited Hospitals | 10,000/- (including cost of PPE Rs. 1200/-) | 15,000/- (including cost of PPE Rs. 2000/-) | 18,000/- (including cost of PPE Rs. 2000/-) |
| Non-NABH Accredited Hospitals | 8,000/- (including cost of PPE Rs. 1200/-) | 13,000/- (including cost of PPE Rs. 2000/-) | 15,000/- (including cost of PPE Rs. 2000/-) |
Inclusions are –
- Consultation
- Nursing Charges
- Room Stay & Meals
- COVID testing
- Monitoring & Investigations –Biochem & Imaging; Physiotherapy
- PPE
- Drugs & Medical Consumables
- Biochemical Waste Management & other Protective gear
- Bed side procedures like Ryles tube insertion, urinary tract Catheterization
Exclusions Per Diem Bases are –
- Interventional Procedures like, but not limited to, Central Line insertion, Chemoport Insertion, bronchoscopic procedures, biopsies, ascitic /pleural tapping, etc, which may be charges at the rack rate as on 31st December 2019
- High end drugs like Immunoglobulins, Meropenem, Parentral Nutrition, Tocilizumab, etc – to be charged at MRP
- High end investigations like MRI, PET scan – to be charges at rack rates of hospital as on 31st December 2019
- Dead body storage & carriage @INR 5000/-
- Treatment of any co-morbid conditions, an additional amount of up to INR 5000/- would be allowed
2. Geographically, the proposed rates are for hospitals as given below –
| Type of City/District | % of CEILING RATE PER DAY |
|---|
| Metropolitan Cities | 100% |
| Other State Capitals | 90% |
| Rest of the country | 75% |
3. As per the type of Hospital, based on the infrastructure & expertise available –
| Type of Hospital | # of beds | # of Minimum Specialities | % of ceiling rate per day |
|---|
| Tertiary Hospital | >100 | 7 | 100% |
| Nursing Homes | 50-100 | 4 | 80% |
| Standalone Hospitals | >50 | 2 | 65% |
** Each Hospital to have an Operational ICU & OT
4. Investigations are a part of the Per Diem cost, however in exceptional cases, some of the diagnostics have to be conducted more frequently than 90% of all cases.
In order to bring about a cost optimization for the most utilised Investigations, some of the capping proposed are –
a. Arterial Blood Gases (ABG) – INR 400/-
b. Blood Sugar Level (BSL) – INR 100/-
c. D- Dimer Levels – INR 800/-
d. Haemograms– INR 150/-
e. CT Chest – INR 3500/-
f. X Ray Chest – INR 500/-
g. ECG – INR 300/-
The costs over cities & hospitals Pan India, would be as follows –
| Type of City | Type of Hospital | NABH Accredited Hospitals (Rs. per day) | Non-NABH Accredited Hospitals (Rs. per day) |
|---|---|---|---|
| Isolation Beds | ICU without ventilator | ||
| Metros | A | 10000 | 15000 |
| B | 8000 | 12000 | |
| C | 6500 | 9750 | |
| State Capitals | A | 9000 | 13500 |
| B | 7200 | 10800 | |
| C | 5850 | 8775 | |
| Rest of the country | A | 7500 | 11250 |
| B | 6000 | 9000 | |
| C | 4875 | 7313 |
** Metropolitan Cities include –
- Delhi & NCR
- Mumbai Metropolitan Region
- Kolkata Metropolitan Region
- Chennai Metropolitan Region
Disclaimer:
“The rates provided in the Schedule of Charges for Covid-19 Treatment costs in Hospitals (Schedule) are reference rates for management of COVID 19 insurance claims. The Schedule has been derived on the basis of experience and shall be reviewed by General Insurance Council every month.
The above stated Schedule is solely intended to facilitate expeditious claim settlement of the policyholders and does not in any manner, whatsoever, interferes with the line of treatment to be prescribed by the treating Doctor/Medical Practitioner or the schedule of charges specified by any statutory and /or regulatory authority. The ultimate judgment regarding the treatment must be made by the physician and the patient in light of all the underlying circumstances and ensuing medical condition of the patient. The information contained in the Schedule is provided for above stated purposes only and shall not be construed as medical advice or any subject matter. General Insurance Council assumes no responsibility with respect to the same.“
