There is no doubt that there has been considerable advancement in medical treatment around the world and in India. But even as allopathy remains the preferred mode of treatment for most patients, there are many votaries for the efficacy of traditional Indian systems such as Ayurveda. What makes many prefer Ayurveda and a few other systems is that they are generally non-invasive, do not have any side effects and work well — especially for lifestyle-related diseases, allergies, skin ailments, select respiratory problems and the like. Broadly, AYUSH or Ayurveda, Unani, Siddha and Homeopathy are the alternative treatment modes opted for by most patients.

But what about health insurance in such cases wherein you take recourse to alternative treatments or medical care? What are the conditions for settling claims for AYUSH treatments and what is the amount allowed for such medical care?

Here’s more on how health insurers cover treatment via alternative modes.

Claiming for AYUSH treatment

The cover for alternative treatment does not come as a separate add-on or a rider. It is usually a part of the regular health insurance policy.

For your claim process to be smooth, you need to know the inclusions and exclusions under AYUSH medical care, and the regulations governing such treatment.

First, you need a written prescription from a medical practitioner to certify that you require alternative treatment and that such care would help improve your health.

For the claim to be accepted, you need to be hospitalised as an in-patient for at least 24 hours. That is, your medical treatment via one of the alternative modes should require a 24-hour stay in the hospital.

The Ayurvedic or other alternative hospital where treatment is prescribed should be run by the Central government or any of the State governments. Claims are also accepted if treatment is done from a government-recognised or accredited institute. Usually, claims for treatment from any other private clinic or hospital are rejected.

Outpatient expenses are not entertained for AYUSH treatments. So, are any pre and post-hospitalisation expenses.

Costs of any diagnostic tests related to AYUSH procedures are also not covered by insurers.

The usual coverage will also be subject to the reasonable and customary charges that the insurer finds acceptable. If hospitalisation charges are exorbitant, then, like limited coverage in the case of allopathic treatment, AYUSH claims are also restricted.

One other point to note is that hardly any insurers cover naturopathy — most do not. Ayurvedic, homeopathic, and to some extent Siddha treatments, are generally covered by most insurers.

Rejuvenation treatment such as using spa services is not covered.

Coverage of insurers

Health insurance companies have a varied approach to settling claims from AYUSH treatments. Some insurers allow claims up to the total sum assured, if the treatment is taken in Central and State government hospitals. They restrict the claim amount otherwise.

Specific covers of HDFC Ergo, Manipal Cigna and ICICI Lombard offer AYUSH claims up to the sum assured in the main insurance policy.

Others restrict the claim to a percentage of sum assured, usually 7.5-25 per cent. And they also subject this maximum percentage with a maximum sum allowed. For example, Star Health Medi Classic offers 25 per cent of sum assured for non-allopathic treatment, but caps the maximum sum to ₹25,000. Bajaj Allianz restricts claims to ₹20,000 for Ayurvedic and Homeopathic treatments.

Royal Sundaram allows claims up to the sum assured if treatment is taken in a government hospital, but restricts the maximum amount to ₹50,000 if treatment is taken elsewhere.

Both cashless settlement as well as reimbursement modes are available from insurers.

Policyholders should be aware of the inclusions and exclusions in health insurance covers relating to AYUSH treatments as they aren’t like regular allopathic medical care. Being aware would help them stay prepared and avoid unnecessary out-of-pocket expenses.

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