Making the most of day care claims in health insurance

Often, getting admitted to a hospital means staying on and getting treatment for ailments over a few days or weeks.

However, for many diseases and medical conditions, the treatment or surgical procedure is done within a few hours and the patient is discharged the same day.

Thanks to developments in medical science and the extensive use of technology, many diseases are treated as day care procedures.

As with other in-patient treatments, all health insurance companies cover day care procedures. Some have co-pay conditions and waiting periods for settling day care treatments. It is also important to understand how cashless settlement works with such treatments so that the entire process is smooth.

Another aspect to note is that day care procedures must not be confused with out-patient department (OPD) cover.

Read on for more on day care treatment claims in health insurance and the claims procedure.

Coverage of ailments

Treatments or surgical procedures for several medical conditions are done within hours. For example, cataract removal from the eyes and surgical procedure for curing sinusitis problems are now day care procedures. Even middle ear operations, nose surgeries, tear duct procedures and tongue reconstruction are completed on the same day of admission.

Bone dislocation procedures, colonoscopy, liver aspiration, piles and fistula removals, prostrate issues are treated as day care admissions.

While most of these ailments are one-off occurrences and treatment is taken accordingly, there are others that require many rounds of medical attention and procedures.

For example, kidney diseases may lead to the requirement of dialysis at regular intervals. Dialysis may even run on a regular basis for years.

Other serious issues such as cancer may require many rounds of chemotherapy and radiation that could continue for months, with continuous follow-ups needed as well, in some cases.

The above list is a small sample of day care treatments. Health insurance companies cover anywhere from 140 to 500-plus ailments that require day care treatments.

Differing from OPD

A mistake many policyholders or even those seeking to buy health insurance make is that they confuse out-patient department or OPD treatment with day care procedures.

For example, a visit to your friendly neighbourhood doctor for a case of cough, cold, fever or mild diarrhoea and some such minor issues where the medical professional prescribes medicines for a few days is not a day care procedure and would not be considered for claims. Some insurers may allow it as part of OPD coverage.

Again, a visit to the dentist to have an extraction done or scaling of tartar or even fixing a painful tooth will not fall under day care treatments.

Any regular health check-up or medical tests done without the express need for those as required by a doctor as part of treatment would not qualify for day care claims.

Therefore, a clear understanding of the difference between OPD and day care treatment is critical to making the most of your health insurance.

Making claims smooth

As mentioned earlier, health insurance companies cover a long list of ailments that require only day care treatments. But a few key points have to be noted so that the claims process works without friction. Obviously, these day care procedures must be prescribed and approved by qualified doctors, and must be availed of at recognised hospitals, preferably within those in the insurer’s list.

Health insurance companies cover day care procedures for an amount up to the sum assured of the policy.

However, for some treatments such as cataract removal, there may be a ceiling on the amount approved for treatment. In the case of cataract, it could range from ₹10,000 to ₹1 lakh per eye.

Most insurers also have waiting periods if the ailment is a pre-existing disease. This period could range at 24-36 months.

Some also have co-payment clauses for day care procedures and so the patient may have to fork out 10-20 per cent of the bill.

For making the day care claims in a cashless manner, ideally, you must take treatment only in a network hospital since most of these procedures would be planned.

A network hospital near your place of residence or that which is easily accessible would be better.

Prior intimation of at least a few days or a week with all medical records and doctor prescriptions must be made to the insurance company or third-party administrator for all planned day care procedures, so that approvals are granted and allowed amounts are known well in advance.

You can take the help of the insurance desk in the hospital where you seek day care treatment and work out a claim arrangement if there are regular treatments and follow-ups required for a few weeks or months.

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