Hospitalization Insurance in Health Insurance

Medical expenses, particularly those resulting from hospital stays, can quickly mount up. Hospitalization insurance, also known as Hospital Insurance or Hospital Indemnity, helps you plan for unexpected medical costs that may arise from a hospital stay. Hospitalization insurance is a type of health insurance that covers hospital stays, outpatient medical care, surgery, and other hospital-related activities involving the insured's health.

In India, while there are no separate covers specifically for hospitalization, every Health Insurance Policy offered across the country covers all related expenses, subject to the sum assured. You can choose to get treated at a network hospital to enjoy cashless hospitalization or be reimbursed for expenses incurred if treated at a non-network hospital.

Features of Hospitalization Insurance Cover

Health insurance policies with hospitalization benefits come with several important features that can save a significant amount of money for the insured. While every insurance plan has different features, some common ones include:

1. Surgery Benefit:

   Most health insurance policies cover surgical procedures under specific circumstances. The expenses must be deemed 'medically essential,' meaning they must be for an operation that is either life-saving, health-improving, or aimed at preventing certain diseases. For instance, Care Health Insurance offers an Operation Insurance Plan that provides comprehensive coverage for expenses associated with specific surgical procedures.

2. Daily Hospital Cash Benefit:

   Insurers provide extra financial protection to cover incidental expenses such as food and travel. SBI's Hospital Daily Cash Insurance, for example, provides a daily cash benefit of up to ₹2,000 per day. In the case of ICU and accidental hospitalization, the sum increases to ₹4,000 per day.

3. Cover for Pre-existing Illnesses:

   After the waiting period for pre-existing illnesses, any hospitalization required due to these conditions will be covered.

4. Ambulance Charges:

   Expenses incurred during the transportation of the patient to and from the hospital are covered by most health insurance policies.

Types of Coverages Under Hospitalization Insurance

1. Pre and Post Hospitalization Cover:

   Several medical tests are performed before a patient is admitted to the hospital. These tests are prescribed by doctors and specialists to ensure the treatment is on track and to prevent errors in judgment. Today, tests are often required even for mild illnesses, so doctors ensure thorough checks before admitting a patient. Tests performed up to 30 days prior to hospitalization are typically covered under conventional health insurance. The number of days, however, may differ depending on the insurance policy. Blood tests, urine tests, X-rays, and other diagnostic tests fall under pre-hospitalization charges.

   After the insured is discharged from the hospital, post-hospitalization expenses are reimbursed. Medicines, follow-up appointments, and diagnostics are covered as part of post-hospitalization expenses. The insurance provider covers clients for up to 60 days after discharge. However, certain therapies such as acupuncture are typically not covered. Again, the length of post-hospitalization coverage depends on the type of policy purchased.

   HDFC ERGO's Optima Secure health insurance offers above-average coverage with 60 days of pre-hospitalization and 180 days of post-hospitalization medical expenses.

2. Day Care Hospitalization Cover:

   Medical procedures requiring hospitalization for less than 24 hours are referred to as daycare treatments. Diagnostics, prescriptions, hospital admission, vital checks, injections, and post-hospitalization charges are all common costs associated with daycare treatments.

   As a result, when all these factors are considered, the total cost of a therapy can be quite considerable. This is where your health insurance comes in handy, as it financially covers your treatment.

   Cataract surgery, nasal sinus aspiration, cancer chemotherapy, cancer radiotherapy, and other common medical treatments are a few examples.

   The IRDAI (Insurance Regulatory and Development Authority of India) included these in health insurance policies because many such treatments can be completed in under 24 hours, are required by many patients, and incur significant healthcare costs.

3. In-patient Hospitalization Cover:

   In-patient hospitalization occurs when you are admitted to the hospital for 24 hours or longer to receive medicine and treatment. There is a distinction between being admitted to the hospital for 24 hours or longer, being sent for specialized diagnostic testing, and being directed to the emergency room for immediate treatment. When hospitalization lasts less than 24 hours, it is not considered inpatient hospitalization.

   Room rent, ICU costs, operating theatre fees, doctor fees, nursing fees, anesthesia, and other expenses may be incurred during inpatient treatment. As a result, for inpatient hospitalization, the health insurance company provides substantial coverage/limit, which will reimburse many treatment-related charges. In most cases, cashless treatments are available in the insurer's network hospitals.

4. Domiciliary Hospitalization:

   Domiciliary Hospitalization is a unique provision in a health insurance policy that allows the insured patient to receive hospital-level treatment at home. The treatment should be for an illness, injury, or disease that would otherwise require hospitalization. However, the patient could not be hospitalized either due to the non-availability of accommodation at the hospital or because the patient's condition did not allow them to be shifted to the hospital. The minimum duration of the treatment should be at least three days.

   Conditions such as Bronchitis, Epilepsy, Asthma, Cough, Cold and Influenza, Diabetes Mellitus and Insipidus, Pyrexia of unknown origin for a period of fewer than 10 days, Chronic Nephritis, Psychiatric or Psychosomatic Disorders, Diarrhea, Dysentery, Gastroenteritis, Arthritis, Gout, Rheumatism, Hypertension, Tonsillitis, Upper Respiratory Tract Infection, Laryngitis, or Pharyngitis do not qualify for domiciliary hospitalization under most policies. For a complete list of these conditions, you should carefully read the terms and conditions of your health insurance policy.

Claims Process

Health insurance companies provide two types of claim settlement processes for your convenience. Here are both claim settlement processes:

Cashless Hospitalization

a) Planned Hospitalization:

• Inform the insurer 48 to 72 hours before hospitalization.
• The insurance company will provide a confirmation letter.
• Submit your health card and confirmation letter.
• The insurer will settle the medical bills directly with the hospital.

b) Emergency Hospitalization:

• Inform the insurer within 24 hours of emergency hospitalization.
• The insurance company will provide a confirmation letter.
• Submit your health card and confirmation letter.
• The insurer will settle the medical bills directly with the hospital.

Reimbursement Claim

• Intimate the company within the designated timeline.
• Collect the original discharge summary and medical bills, and submit them with the claim form.
• Fill and submit the claim form along with ID proof (Voter ID/Aadhaar Card/PAN Card) and a cancelled cheque.
• The insurance company will evaluate the documents.
• The insurance company will initiate the reimbursement process.