At the peak of the Covid pandemic, there were widespread reports of hospital beds being unavailable for new patients looking for admission and treatment. Imagine facing a situation like that or a few other unforeseen circumstances where you are forced to take treatment for your health condition at home.

But do health insurance companies entertain claims for treatment taken at home?

That’s where domiciliary coverage of health insurance plans comes into the picture. When is domiciliary treatment allowed, how is the claim settled and which ailments and treatment modes aren’t entertained by health insurance companies? Here’s what you must know about Domiciliary hospitalisation claims in health insurance.

When is domiciliary treatment allowed?

It is not as if you can stay at home and get all the treatment required because you find the set-up comfortable and familiar. Insurance companies have specific rules on accepting such claims. At least one of the following conditions is generally required for insurance companies to accept claims.

First, a registered medical practitioner must certify that it is better for you to be treated at home in the present circumstances rather than moving you to a hospital ward.

Of course, you should have otherwise needed inpatient treatment at a hospital.

Second, it must be proved that there are no suitable hospital beds available at network or non-network hospitals near your place of residence or even within the city. That is, hospitals running with full patient capacity may not be in a position to admit you, thus necessitating treatment at home.

Third, a registered doctor must certify that shifting you to a hospital may aggravate or worsen your present health condition and that treatment at home would be a better option under the circumstances.

Insurance coverage

Policies from companies such as HDFC Ergo (health suraksha), ICICI Lombard (health advantadge), Niva Bupa (ReAssure), Star Health (comprehensive insurance) and Royal Sundaram (family plus) cover domiciliary treatment expenses.

Often, domiciliary hospitalisation claims are settled on a reimbursement basis. So, you will have to pay first and register your claim later. Usually, the treatment costs are covered.

But there are some nuances to specific policies of health insurers. Pre- and post-hospitalisation expenses are among these.

Niva Bupa’s ReAssure does not pay them, even though it allows cost of treatment.

However, Royal Sundaram’s family plus policy says that if a claim is accepted under domiciliary treatment, then pre and post-hospitalisation expenses are also covered.

If the doctor treating you recommends a qualified nurse to attend to your needs on the path to recovery, then ICICI Lombard’s health AdvantEdge allows that expense as well.

What’s excluded

Insurers do not allow domiciliary hospitalisation claims for all kinds of ailments. For a claim to be entertained, your treatment must last for at least three continuous days. For any period less than that, insurers mostly reject such claims.

Star Health allows claims for AYUSH (ayurveda, unani, siddha and homeopathy) treatment, too, while most insurers reject such claims.

Almost all insurers refuse to entertain claims for a host of ailments. These include asthma, bronchitis, tonsillitis and upper respiratory tract infection, including laryngitis and pharyngitis, cough and cold, and influenza.

Other common occurrences such as arthritis, gout and rheumatism,  chronic nephritis and nephritic syndrome, diarrhoea and all type of dysenteries including gastroenteritis, diabetes mellitus and insipidus, epilepsy, hypertension, and pyrexia of unknown origin.

In short, normal outpatient type treatments where you visit a doctor, take prescribed pills and rest adequately to recover will not be entertained. Chronic conditions that require prolonged outpatient or home-based care will also not be covered.

You must maintain all documents, doctor certificates and recommendations, prescriptions and receipts pertaining to your domiciliary treatment carefully, so that your reimbursement process is smooth.