Hospitalization Insurance in Health Insurance

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

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

Features of Hospitalization Insurance Cover

Health Insurance policies with hospitalization benefits come with a number of important features that can save a significant amount of money for the life insured. While every insurance plan comes with different features, some of the common ones are:

1. Surgery Benefit :

   Most health insurance policies cover surgical procedures under certain circumstances. The expenses must be deemed ‘medically essential' which means that they must be for an operation that is either life-saving, health-improving, or aimed to prevent 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 expenses such as food and travel. SBI's Hospital Daily Cash Insurance, for example, provides a daily cash benefit of up to Rs. 2,000 per day. In the case of ICU and accidental hospitalization, the sum increases to Rs. 4,000 each day.

3. Cover for Pre-existing Illness :

   After the waiting period associated with pre-existing illnesses, any need for hospitalization resulting out of these conditions will be covered.

4. Ambulance Charges :

   Expenses incurred during 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 that the treatment is on track and that no errors in judgment have occurred. These days, tests are required even to cure mild illnesses, so doctors leave no stone unturned before admitting a patient to the hospital. The tests performed prior to 30 days of hospitalization are normally covered under any conventional health insurance coverage. The number, however, may differ depending on the insurance. Blood tests, urine tests, X-rays, and other tests fall under the heading of pre-hospitalization charges.

   After the insured has been discharged from the hospital, post-hospitalization expenses are reimbursed. Medicine, follow-up appointments, and diagnostics are paid as part of the post-hospitalization expenses. The insurance provider covers clients for up to 60 days after they've been discharged. However, therapies such as acupuncture and others are not covered. Again, the length of post-hospitalization coverage is determined by 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 post-hospitalization medical expenses.

2. Day Care Hospitalization Cover :

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

   As a result, when all of these factors are considered, the total cost of a certain therapy can be rather 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 only a few examples.

   The IRDAI (Insurance Regulatory and Development Authority of India) implemented the same in health insurance policies due to the fact that many such treatments can be completed in under 24 hours and are not only required by many patients but also incur large health care costs.

3. In-patient Hospitalization Cover :

   In-patient hospitalization is when you are admitted to the hospital for a period of 24 hours or longer and get medicine and treatment. There is a distinction between being admitted to the hospital for 24 hours or longer, being sent to the hospital for specialized diagnostic testing, and being directed to the emergency room for immediate treatment. When a hospitalization lasts less than 24 hours, it is not considered an 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, in the case of inpatient hospitalization, the health insurance company gives a substantial cover/limit, which will reimburse a lot of treatment-related charges. In most cases, cashless treatments are available in the insurer's network of hospitals.

4. Domiciliary Hospitalization :

   Domiciliary Hospitalization is a unique provision in a health insurance policy that allows the insured patient to be admitted to the hospital while still at home. The treatment should be carried out for an illness, injury, or disease for which hospitalization was required. However, the patient could not be hospitalized either due to the non-availability of accommodation at the hospital or because the condition of the patient did not allow him/her 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, and Gastroenteritis, Arthritis, Gout, or Rheumatism, Hypertension, Tonsillitis, and 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 read the terms and conditions of your health insurance policy carefully.

Claims Process

Health insurance companies provide 2 types of claim settlement processes to choose from at your convenience. Take a look at both claim settlement processes in the section below:

Cashless Hospitalization

a) Planned Hospitalization :

• Inform the insurer before 48 to 72 hours of hospitalization.
• The insurance company to 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 before 48 to 72 hours of hospitalization.
• The insurance company to 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 original discharge summary and medical bills and submit with the claim form.
• Fill and submit the claim form along with ID proof (Voted ID/Aadhaar Card/PAN Card) and a cancelled cheque.
• The insurance company will evaluate the documents.
• The insurance company will initiate the reimbursement process.

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