Telemedicine Claims Work Like OPD, But Only With Proof Your Insurer Accepts

Telemedicine consultations have picked up, especially after the pandemic. In certain cases, that is all that you may require, and a physical visit to the doctor may not be necessary. Does your insurance cover such consultations?

What Is Covered 

It is highly recommended that policyholders check the telemedicine reference included in their individual policy documents prior to using any related services provided by the insurer. Each type of telemedicine service has its own unique categorization; thus, the benefits associated with those telemedicine services vary by insurer and also by the specific product design created by this insurer.

“Some policies will provide benefits for all telemedicine services (including econsult/list and telemedicine services to support general doctors, specialists, chronic disease management follow-ups, and mental health), while others are limited to certain categories or partner platforms only,” says Arun Ramamurthy, co-founder, Staywell.Health.

Some policies include teleconsultations as a value-added service through insurer-approved apps or partners, while others reimburse only when OPD cover is specifically opted for. “Customers should verify where telemedicine fits in their policy, whether it is part of OPD, wellness, or a bundled service—so there are no surprises at the time of claim,” says Narendra Bharindwal, president, Insurance Brokers Association of India (IBAI).

By verifying which types of telemedicine services are covered under the specific insurer and specific product, policyholders can avoid confusion with respect to what types of telemedicine services are eligible for reimbursement and how to file a claim for reimbursement for those services.

Coverage May Come With Limits 

In addition to verifying coverage for telemedicine services, policyholders need to pay close attention to any sub-limitations and/or conditions associated with the telemedicine benefits provided under their policy. “Sub-limitations may include the maximum number of telemedicine consultations allowed per insured, the maximum allowed reimbursement amount per telemedicine consultation, and the requirement for a telemedicine consultation to be conducted by a registered medical practitioner on an approved platform,” says Ramamurthy.

“Moreover, any services/services related to telemedicine (such as e-prescribing, tele-diagnosis, and remote monitoring of vital signs) may also be subject to defined inclusions/exclusions for coverage. Understanding the limitations on the telemedicine benefit will provide policyholders with realistic expectations surrounding their coverage for telemedicine services,” says Ramamurthy.

How To File A Claim 

Typically, customers must use an insurer-approved platform(s) or ensure that their visit follows their insurance company's specific guidelines (e.g., the doctor providing the service must be licensed) in order for the customer to claim telemedicine expenses. Documentation of the telemedicine visit would most likely include digital consultation records, invoices, e-prescriptions, and proof of payment.

The customer files their claim through their insurance company's app(s) or online portal(s), and the length of time it takes to receive reimbursement from their insurance company varies based on the customer's insurer and the type of claim submitted.

“If all documents are in order, reimbursement timelines are similar to OPD claims, typically ranging from seven to 15 working days, depending on the insurer,” says Bharindwal.

“By following the necessary process and saving all digital documents, the customer will have a much greater chance of receiving a faster settlement of their claim,” says Ramamurthy.