When you get diagnosed with a disease or meet with an accident and need to undergo treatment or surgery - there are not just hospitalisation costs involved. You’ll also have to incur expenses for conducting tests to know the severity of the injury or the illness. Then, after you’re discharged from the hospital, you might have to visit the doctor for check-ups or undergo physiotherapy sessions for faster recovery or some tests for monitoring purposes.
Will your health insurance policy cover all these costs you incur prior to and after a hospitalisation? If yes, under what conditions? And how to claim post-hospitalisation expenses and pre pre-hospitalisation expenses under health insurance?
Let's find out.
What are Pre-hospitalisation Expenses? Are they covered under Health Insurance?
All expenses that you incur prior to any hospitalisation come under pre-hospitalisation expenses. These include the costs of tests conducted for diagnostic purposes, like blood tests, urine tests, x-rays, etc.
In India, all health insurance policies cover pre-hospitalisation expenses. The number of days up to which you can claim for the pre-hospitalisation expenses will vary from insurer to insurer. Normally, expenses up to 30 to 90 days before the hospitalisation are covered under health insurance.
Conditions for Coverage of Pre-hospitalisation Expenses in Health Insurance
Here are some general conditions around coverage of pre-hospitalisation expenses in health insurance.
👉 Coverage limits
Generally, most insurance companies cover the pre-hospitalisation expense up to your base policy sum insured. However, a few insurers might impose a specific limit up to which you can claim for pre-hospitalisation expenses. For instance, United India's Family Medicare policy will cover the pre-hospitalisation expenses of up to 10% of the sum insured.
So, if you have a health insurance plan of INR 5 Lakh, it will cover pre-hospitalisation expenses up to INR 50,000 (10% of 5 Lakh). If your pre-hospitalisation costs are above INR 50,000, you will have to pay for them out of your pocket.
👉 Inpatient hospitalisation is mandatory
You can claim the pre-hospitalisation benefit in your policy only if you undergo an inpatient hospitalisation for further treatment, meaning you're admitted to the hospital for more than 24 hours continuously.
👉 Restrictions based on types of illnesses
While all health insurance policies in India cover pre-hospitalisation expenses, there might be restrictions based on the types of illnesses for which the policy will provide the pre-hospitalisation benefit. So, ensure you go through the policy document before you finalise a plan.
Insurers like Aditya Birla, Digit, Oriental, National, and Magma cover pre-hospitalisation for psychiatric illnesses as well. However, other insurers don't cover pre-hospitalisation costs of psychiatric illnesses at all. Further, Max Bupa covers pre-hospitalisation physiotherapy expenses if it is prescribed by the treating doctor.
Please note: The above conditions and limits may vary across insurance companies. Ensure you go through your policy documents before you opt for this benefit.
What are Post-hospitalisation Expenses? Are they covered under Health Insurance?
Costs that are incurred after you’re discharged from the hospital come under post-hospitalisation expenses. For instance, costs of tests done for observation or monitoring purposes, physiotherapy sessions, routine follow-up checkups after you undergo surgery or treatment, etc.
Post-hospitalisation expenses are covered under all health insurance policies in India. Generally, post-hospitalisation expenses up to 60 to 180 days after being discharged from the hospital are covered under health insurance. This number, however, might vary from insurer to insurer.
Conditions for Coverage of Post-hospitalisation Expenses in Health Insurance
For Post-hospitalisation expenses to be covered under your health insurance policy, there are certain conditions that need to be met.
👉 Costs should be related to the same illness for which you were hospitalised
You can use the post-hospitalisation benefit under your health insurance only for the same illness or treatment for which you were hospitalised.
Say you underwent hospitalisation for dengue. Now, only the post-hospitalisation expenses of dengue will be covered by your policy. If you undergo tests for some other medical condition, say thyroid, then the costs won't be covered under your policy.
👉 Coverage limits
The limit up to which you can claim under the post-hospitalisation benefit will vary from insurer to insurer. Some insurers don't specify any limit in the policy document; that is, they cover the post-hospitalisation costs up to your base sum insured. However, there are insurers that mention a limit. For instance, United India's Family Medicare policy covers post-hospitalisation expenses up to 10% of the sum insured.
👉 Claim must be accepted under the inpatient benefit
Post-hospitalisation expenses will be covered only if you undergo hospitalisation for a continuous period of 24 hours or more, and the insurance company has approved a claim under the inpatient benefit under your health insurance plan.
👉 Should be prescribed by the treating doctor
The insurance company will cover only those post-hospitalisation costs under your policy that are prescribed by the treating doctor. For instance, you undergo heart surgery, and one month after you're discharged, you get an X-ray of your heart done, but it is not prescribed by the doctor who conducted the surgery. Such costs will not be covered by your policy.
👉 Available for specific benefits
While all health insurance policies cover post-hospitalisation expenses that you incur after you undergo an inpatient hospitalisation, there are some policies that also cover post-hospitalisation expenses that are incurred for psychiatric illnesses, organ donations, and home healthcare. Some policies that allow this are -
- Aditya Birla Active Health
- Digit Health Care Plus
- Magma One Health Policy
- National Insurance Mediclaim Plus Policy
- National Insurance Parivar Mediclaim Plus Policy
- Oriental Mediclaim Insurance Policy
Please note: The limits and conditions mentioned above may vary across insurance companies. Ensure you go through your policy documents before you opt for this benefit.
How to Claim Pre Hospitalisation and Post Hospitalisation Expenses?
It is very much required that you know how to claim these expenses while making the best out of your insurance policy. Let's look at the process-
➡️Submitting Claims
Once you are discharged from the hospital, you can claim expenses related to pre- and post-hospitalisation. Remember to submit all the documents in time, preferably within 30 days following your hospitalisation. However, please note that this period differs in various insurance plans. It varies between 60 days and 90 days. Review your policy details carefully to ensure your documents are submitted correctly.
➡️Collecting Documents
Collect all pertinent bills, test receipts, original reports, and doctor’s prescriptions associated with your pre- and post-hospitalisation costs.
➡️Claim Form
Fill in the claim form with every detail of your expenditure incurred before and after hospitalisation. No expense must go unmentioned.
➡️Submit Your Claim
After filling out the claim form, submit it to the insurance company along with all the gathered bills, receipts, reports, prescriptions, etc. Ask the insurer for an exhaustive list of papers to be attached, so nothing is missed.
➡️Document Delivery
Submit your documents through email, courier, in person at a branch, or directly to your agent. Check with your insurer to verify their preferred method of submission, as it can differ. It is always advisable that you make a copy of everything you are submitting to the insurer so you can refer to it in case of a query.
Time Limit For Coverage
The cost incurred by the patient during hospitalisation and after discharge is only covered within the stipulated time frames.
- Pre-hospitalisation Phase: 30 to 90 days
- Post-Hospitalisation Phase: 60-180 days
Keep in mind that expenses exceeding the limits specified in your policy document will not be covered.
Please Note: The number of days may vary based on your insurance plan.
Coverage Conditions
Expenses related to treatment for the same illness for which you were hospitalised and your claim must be approved under inpatient/daycare treatment, will only be covered by the insurance company.
Documents Required
Let’s list down the documents required to claim pre-hospitalisation and post-hospitalisation expenses-
- Original copies of hospital bills
- Relevant medical certificates
- Original prescriptions by the doctor
- Hospital discharge summary
- Bills for medicines and drugs
- Any related documents needed by the insurance company
Benefits Of Pre & Post Hospitalisation Coverage: Reasons To Buy Health Insurance With Pre & Post-hospitalisation Cover
Let’s look at the various advantages of pre- and post-hospitalisation-
Protection:
Health Insurance is one of the safest means of protecting you and your family, as it caters to all expenses incurred either before or after hospitalisation. Health insurance plans would cover your whole process of medical treatment, prior to hospitalisation, throughout your hospital stay, and following your discharge. It could give you peace of mind knowing you are getting the care you will require without worry of gaps in coverage.
Comprehensive Coverage for Major Treatment Costs:
The cost of treatment and drugs often far exceeds the hospital stay. For example, a short in-hospital stay might be followed by ongoing therapy, frequent follow-ups, or medications that are required for weeks or even months post-discharge. Insurance that covers such post-hospitalisation expenses ensures your treatments without jeopardising the stability of your financial situation.
Cashless Facility:
The benefit of choosing to get treated in a network hospital of your insurance company is that you can enjoy the benefits of cashless transactions and more. It will reduce paperwork and stress so that you can divert your attention from the finances to your health.
Minimised Financial Burden:
Medical emergencies can be quite unexpected and put a heavy strain on your finances. Therefore, coverage related to expenses prior to and following the hospitalisation comes as a relief. That way, you get to handle medical needs without letting them exhaust all your savings or catapult you to the banks. This financial assistance guarantees you can receive the healthcare you need without financial stress.
Decreased Stress Levels:
Knowing all your costs incurred before and after hospitalisation are covered automatically means you can keep your attention focused on recovery rather than on bills. Mental clarity is crucial to healing because you do not have to worry about accumulating bills while getting better.
Readiness for Emergency Situations:
Extensive coverage makes you more prepared for any other unforeseen medical concerns that may emerge even after you are discharged from the hospital. With both pre- and post-hospitalisation coverage, whenever a new complication or associated health concern arises, you can see a doctor immediately without batting an eyelid, ensuring your health above everything else.
Things To Remember While Buying Health Insurance With Pre & Post-hospitalisation Cover
Here’s what you need to keep in mind while buying pre- and post-hospitalisation coverage with your health insurance policy-
Coverage Limit:
Typically, insurers cover pre- and post-hospitalisation expenses up to the base sum insured of your policy. However, some providers may set limits, such as covering only 10% of the sum insured for these expenses. Be sure to check your policy document for specific coverage details.
Requirement for Inpatient Hospitalisation:
Pre- and post-hospitalisation benefits can only be claimed if you have received inpatient treatment, meaning coverage applies only if you were admitted to the hospital for more than 24 hours. Some insurers also cover pre and post-hospitalisation costs if you undergo daycare treatment. Daycare treatment refers to medical procedures or surgeries that previously required a prolonged hospital stay but can now be completed within 24 hours due to advancements in medical technology.
Disease-Specific Limitations:
Pre- and post-hospitalisation costs might be covered for specific diseases, and the same can be curtailed for specific illnesses. See the policy documents issued and try to observe the typical/demarcated limitations or exclusions related to a particular kind of illness.
Reimbursement Claims:
Most health policies insist that a claim for reimbursement be filed regarding pre- and post-hospitalisation expenses. That means you would have to pay the charges beforehand and then file your claims with the insurer, who, in turn, reimburses you.
Hospitalisation Related Costs:
All pre- and post-hospitalisation costs must be related directly to the illness that caused your hospitalisation. Expenses for conditions unrelated to the claim are not eligible for coverage.
Prescription by a Doctor:
All pre- and post-hospitalisation expenses must be prescribed by the treating doctor to be eligible for coverage. Any tests or treatments should be recorded by your doctor as necessary.
Access to Specific Benefits:
Certain policies offer extra coverage for post-hospitalisation expenses associated with psychiatric conditions, organ donations, and home healthcare. Check your policy for additional benefits under your specific insurance plan.
Important Note: Coverage conditions vary among providers. Ensure that you read your policy documents for proper information about your coverage details.
When Are Pre And Post Hospitalisation Claims Not Accepted?
Pre- and post-hospitalisation claims are usually not approved for the following reasons:
- Time gap: The claim has been raised beyond the allowed period, usually 30 days following discharge or 45–90 (note that days can be different for every insurance policy) days following the hospitalisation.
- Mismatched treatment: The claimed treatment differs from the treatment actually availed under inpatient or daycare treatment.
- Missing documents: The needed papers were either not submitted on time or were missing.
- Unrelated illness or injury: The claim is based on an illness or injury that the insurance policy does not cover or is merely not related to your hospitalisation.
Conclusion
Even though the coverage about pre- and post-hospitalisation might not be the most scintillating part of your insurance policy, it is certainly a very crucial one. It will make sure that your financial health journey is going smoothly. Before you invest in a health insurance plan, always get your fingers on the fine print about this coverage, as policies do vary substantially. A little extra attention to detail today will save you from any big surprises later on.
After all, it's just about giving you that peace of mind to get along with your life's business, concerning health and recovery.
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