Insurance against a runny nose: What in the policy can be considered "flu"?

As winter approaches, many of us catch colds and start sneezing and coughing. Some insurers offer special voluntary medical insurance programs for those who get the flu or acute respiratory diseases every winter. Can such a policy protect its holder from seasonal illnesses?

Insurance companies engaged in voluntary health insurance (VHI) have not yet developed a general approach to protecting against the flu. Some have offered citizens vaccinations followed by insurance against the disease itself. For example, about a month ago, GUTA Insurance announced a VHI program called "Protection from Influenza." This program provides mandatory vaccination against influenza using vaccines recommended by the WHO and pays compensation in case of illness or complications within a year after vaccination. In other words, the vaccine's effectiveness is assumed to last a year. The policy, which has an insured amount of 50 thousand rubles, costs only 450 rubles. The company guarantees that, in case of infection and hospitalization, the client will receive compensation for each day spent in the hospital.

The offer is tempting: for a small fee, clients receive vaccinations and guaranteed treatment if the vaccine is ineffective. It remains to be seen why other insurers did not offer such a service. "Ingosstrakh organizes and pays for outpatient and inpatient services provided to the insured in case of acute illnesses or exacerbation of chronic diseases, including influenza," says Andrey Dmitrenok, the deputy director of Ingosstrakh's health insurance department. According to Dmitrenok, "There is no separate insurance program for influenza. It is impossible to single out this disease, as it is often difficult to differentiate between acute respiratory infections, other viral infections, and influenza. It is also impossible to distinguish influenza due to possible complications, such as pneumonia or endocarditis, which require additional diagnostics and treatment." Indeed, pneumonia is not necessarily a consequence of influenza; it may have other causes. However, Ingosstrakh may offer clients a flu vaccination in addition to the basic program.

ROSNO does not have a program that provides insurance only against influenza. "A comprehensive voluntary health insurance program may include outpatient care, emergency medical care, and inpatient care, depending on the selected option, and provides medical care for a wide range of diseases, including influenza," says Nina Egorkina, Head of the Health Insurance Center at ROSNO, stressing that influenza immunoprophylaxis is not included in the basic version of the comprehensive program but can be added at the client's request.

The Energogarant insurance company offers a separate program for those who wish to purchase flu insurance. "Our company offers a comprehensive flu insurance program," says Natalia Klimenko, director of the personal insurance department at Energogarant. "It includes outpatient and inpatient medical care in case of flu and its complications. In this case, the insurance company organizes and pays for treatment depending on the medical indications and severity of the insured's condition." Klimenko emphasizes that a “flu” diagnosis in this case should not be confused with ARVI. Under this program, ARVI is not an insured event due to its different clinical symptoms and causative agents. Moreover, "the final diagnosis can be made only after the influenza strain has been isolated." When concluding a contract under the "Influenza and Its Complications" program, Energogarant offers treatment at various facilities specializing in infectious diseases. The cost of the program depends on the level of the treatment facility. However, the cause of these complications must be influenza; only then will the insurance company pay for treatment. When concluding a contract under the "Influenza and Its Complications" program, the insurance company offers treatment facilities for infectious diseases. Depending on the level of the treatment facility, the cost of the program is determined.

It can be assumed that the main problems are related to complications occurring. What should the insured do if the doctor doubts that the complication is flu-related? Nothing but agree. However, the insurance company is interested in a clear flu diagnosis because it determines whether the company will pay for the medical institution's activities. According to Energogarant, if the insurance company believes the diagnosis is unjustified, the insured person is referred to a clinical-expert commission. This commission is available at any medical institution and includes several highly qualified doctors. If the commission's conclusion is not satisfactory to the insurance company, an independent expert is called in, and the dispute is resolved in court.

In general, it's clear that to avoid unnecessary proceedings, it's better not to get the flu. The only advantage of a specialized program may be its affordability compared to the standard VHI program, which most insurance companies include for flu treatment. But this argument is for the insured. As for insurers, the main reason separate flu programs are not popular with them is, of course, the uncertainty of diagnosis. "Influenza is an acute disease," explains Olga Karpicheva, head of the Medical Programs Department at OJSC "Kapital Insurance." "Any acute illness (in this case, influenza) is an insured event. Therefore, medical services rendered to the insured under our 'Polyclinic' program in connection with the flu are paid by the insurance company."

Alexander Lapunov, the deputy head of the medical insurance department at Alfa Insurance Group, takes a similar approach. In his opinion, "influenza is not a specific disease and cannot be an independent risk, meaning it cannot be calculated as a separate insurance product. However, flu is included in almost any insurance program that includes ambulatory and polyclinic services."

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