Health insurance is not widely understood in India. Very few actually are aware of it, out of those who know about health insurance some think it is similar to Life insurance, which it is not. Others don’t know that mediclaim as it is known in India, only covers hospitalization charges not all health expenses. In this article, everything about hospitalization vis-à-vis insurance, like what it covers and doesn’t will be explained.
Health insurance Companies have defined terms like hospital, hospitalization period, domiciliary hospitalization so that there is clarity about what is paid and what is not.
Here are some of the common definitions and what they mean
1) Hospital means any institution in India established for the indoor medical care and treatment of patients and which either:
a) Is registered and licensed as a hospital or nursing home with the appropriate local authorities and is under the Supervision of a Doctor in attendance 24 hours a day and is not, except incidentally, a clinic, nursing home, rest home, or convalescent home for the addicted, aged, mentally disturbed or similar institution, or
b) Complies with at least the following criteria:
i) It has at least 10 inpatient beds;
ii) It has a fully equipped and functioning operating theatre;
iii) It has qualified nursing staff (any person who holds a certificate issued by a recognized nursing council) in attendance 24 hours per day;
iv) It has a Doctor who is in attendance 24 hours per day;
v) It maintains daily medical records for each of its patients
What it means: It means that you can’t just go to any hospital in your neighborhood or admit yourself in your General Physician’s clinic with two beds. Health Insurance Companies in order to ensure quality and standard care to the patients make these conditions mandatory.
So before you get yourself or someone near you admitted make sure these basic conditions are fulfilled.
2) Hospitalization period: Hospitalization expenses will only be paid if hospitalization is for more than 24 hours.
It means that a visit to the hospital does not result in a payable claim per se. You need to be admitted for valid reasons for more than 24 hours for the coverage.
Exceptions: There are number of treatments called as ‘Day Care Treatment’s which are covered even if they require less than one day of hospitalization. Some of these include- eye surgery, chemotherapy, tonsillectomy, surgery of throat etc. For the extensive list, read the policy wordings of the insurance company.
*There also might be a condition in some policies that these day care treatments need to be taken care of in Network Hospitals only.
What won’t be paid? There are some treatments that wouldn’t be paid in the first year of the policy even if they require more than 24 hours of treatments like Cataract, Hernia, Gastric ulcer, Dialysis of Chronic renal failure and internal tumors. Similarly there are treatments that wouldn’t be paid for in the first 2/4 years. For more extensive list see your policy wordings.
3) Pre- Hospitalization expenses: These are medical expenses relevant to the disease that results in hospitalization incurred during a period up to the number of days specified in this policy, prior to hospitalization for treatments of disease, illness or injury sustained as part of a claim admissible under the policy.
What it means: It means that you can claim all medical expenses that you undertook for the treatment before you were hospitalized, if the hospitalization is payable. Generally, all expenses incurred 30 days before the hospitalization can be claimed by providing proper receipts and reports required.
4) Post Hospitalization Expenses: These are medical expenses relevant to the disease that resulted in hospitalisation incurred during a period up to the number of days specified in the policy, after hospitalization for treatments of disease, illness or injury sustained as part of a claim admissible under the policy.
What it means: It means that all the medical expenses incurred after the hospitalization can be claimed by the individual if the hospitalization is covered. Generally medical expenses up to 60 days from date of discharge can be claimed by the person after submitting relevant documents and receipts.
What all is paid?
a) Ambulance charges:
Ambulance charges will be paid in case the person has to be shifted from residence to hospital in Emergency/ ICU or from one hospital/Nursing Home to another Hospital/ Nursing Home by registered ambulance only for better facilities.
It means that Ambulance charges will only be paid in case of emergency or when patient is shifted to other hospitals for better facilities.
b) Domiciliary treatment:
Medical treatment exceeding three days for such illness/disease/injury which in the normal course would require care and treatment at hospital/nursing as in- patient home but actually taken whilst confined at home in India under any of the following circumstances namely:
i) The patient is in such a condition that he/she cannot be removed to the hospital / Nursing Home.
ii) The patient cannot be removed to Hospital/ Nursing home due to lack of accommodation in any Hospital in that city/ town/village.
Domiciliary treatment means that when the patient is not in a condition to be moved or when there is no availability of beds in hospitals, the medical care taken at home is payable.
But you will not be paid for Pre and Post hospital Treatment and if you need treatment for diseases like Asthma, Bronchitis, Diabetes Mellitus, Cough, Colds, Arthritis, Gout, Rheumatism. Etc.
c) Diagnostic Tests:
Generally Insurance Companies only pay for Diagnostic tests if the individual is found to be positive with disease specified and if the disease is covered in the policy. This expense is taken under the pre- hospitalization expenses.
All diagnostic tests done during valid hospitalizations are covered in the policy
Most policies however pay for such tests upto a percentage of Sum Insured after a given number of claim-free years of cover.
If you are aware about what is payable and what is not then you will be in a better position with clearer expectations from the insurance company. The insurance company will then be less likely to disappoint you or reject your claim.