Ramesh was a man of preparedness. He was the school principal who, time and again, used to tell his students to think for the future and plan it accordingly. Back home, as a father of two, he would ensure his family's proper care, be it education, savings, or health. Nothing, however, on earth could have prepared him for what was destined to unfold on one rather cold winter night.
His aged mother had been suffering from acute arthritis—a joint infection for years and suddenly was stricken with a dangerous fever that appeared to come out of nowhere. Alarmed, Ramesh called the family doctor without losing a minute. The verdict was crystal clear: she needed medical attention and hospitalisation as recommended by the doctor. Without losing any time, he took her to the nearest hospital, expecting the required care would just be a step away.
There, he found an unforgiving reality—the available beds were exhausted. Every ward was packed full, and all the hospital could do was extend their regrets. Fed up yet resolute, Ramesh headed back home with his mother, feeling drained and hopeless. Was there any way she might be able to get the intensive care she desperately needed?
That’s when their family doctor suggested an alternative: domiciliary hospitalisation. This provision in health insurance allows patients to receive hospital-like care at home under specific conditions. Medical equipment, nursing care, and even doctor consultations—all in the comfort of your home. Desperate to help his mother find the best remedy, Ramesh dived into understanding how this worked.
What would you do if you were in the place of Ramesh? Would your health insurance policy cover such a situation? Do you know what domiciliary hospitalisation is and how it differs from home care?
We take it one step at a time by going over Ramesh's case and everything you would like to know about domiciliary hospitalisation. You will know what it doesn’t cover, how, and in what cases, so it is well-kept and readily available in times of health emergency.
What is Domiciliary Hospitalisation?
Domiciliary hospitalisation meaning is simple. It refers to medical treatment provided at home for diseases, injuries, or disorders which, in normal circumstances, would have necessitated hospitalisation. However, they are instead conducted at home under 'specific circumstances'. The circumstances included are as follows:
- The patient is not fit to be moved to a hospital.
- Hospitals in the vicinity of the patient don’t have available beds.
In such scenarios, the treatment is administered at home, though it would normally be carried out in a hospital.
The next thing Ramesh came across was a domiciliary claim, making him wonder what it was. Read on further to know what he found out!
What is a Domiciliary Claim?
The domiciliary claim is a part of the health insurance policy, which allows claiming the incurred medical cost in case of domiciliary hospitalisation. Therefore, even if the treatment is carried out at home the cost of it will be covered by the insurance company. Basically, the insurer pays for the medical costs for home treatments, procedures, or nursing care.
As discussed above, there are some terms and conditions for the domiciliary claim so that the treatment of the insured or his family member is not undertaken voluntarily.
Now what worried Ramesh was how is this domiciliary hospitalisation incorporated into a health insurance policy? Here we are to help you with your doubts.
Let’s Get Into the Details of Domiciliary Hospitalisation in Health Insurance
Domiciliary hospitalisation is covered by some health insurance policies. Therefore, please refer to your policy to determine if it includes the benefit of domiciliary hospitalisation. If your policy includes it, then it will only be applicable under specified circumstances.
Here are certain general conditions which should be met to get domiciliary hospitalisation coverage:
👉Cap on Coverage
Some health insurance policies have a cap on the expenses of domiciliary hospitalisation. This is to say, the insurer would only pay the costs up to the specified coverage limit and all the extra expenses would be covered by you.
For example, if Ramesh’s policy provided coverage of INR 2 Lakh for domiciliary hospitalisation, but the total expense of treatment crossed INR 2.5 Lakh, the insurer would pay up to INR 2 Lakh. The rest of INR 50,000 would be paid from Ramesh’s pocket.
👉Minimum Treatment Duration Requirement
In most instances, the treatment needs to be delivered at home for at least three consecutive days before the coverage becomes applicable. Again, this will depend on the specific plans you choose. A few examples are Tata Medicare Premier, Reliance General Health Gain (Power) and Star Health Comprehensive, among others.
👉Pre and Post-Hospitalisation Costs
Under domiciliary treatment coverage, most health insurance policies do not cover the cost incurred by you before or after your hospitalisation, which includes tests and x-rays done for diagnostic and observation purposes, etc. However, some policies cover these costs too, such as Aditya Birla Health Activ Assure Plan, HDFC Ergo Optima Restore Plan, etc.
👉Excluded Treatments and Conditions
Coverage for domiciliary hospitalisation may be excluded in some insurance plans in cases of a few health conditions or treatments, including diabetes, respiratory disorders, diarrhoea, infertility, and maternity. Further, alternative medicine (Ayurveda, Unani, Siddha, Homoeopathy, Naturopathy) treatments may not be covered.
👉Certification from Doctor
Some insurers will demand certification from the doctor who is providing the treatment confirming that the medical conditions stipulated for domiciliary treatment are real and the duration required for the treatment..
Note: Keep in mind that the specific conditions for domiciliary hospitalisation coverage can vary between insurance providers. The points mentioned here are general guidelines commonly found in health insurance policies. There may also be additional terms or hidden clauses unique to each insurer. Therefore, it’s crucial to thoroughly review the policy document to ensure the plan meets your requirements and provides the coverage you need.
After knowing what was covered under this coverage, Ramesh was curious to know its exclusions as well!
Treatments Not Covered in Domiciliary Hospitalisation
Certain insurance plans, such as HDFC Ergo Optima Secure, Bajaj Allianz My Health Care, etc., provide comprehensive coverage for domiciliary treatments. However, others, like ICICI Lombard Elevate, Tata AIG MediCare Premier, etc., may have limitations and do not cover all treatments.
Here are some examples of treatments that are typically excluded from domiciliary hospitalisation coverage:
- Respiratory Conditions: Common respiratory issues such as asthma, bronchitis, tonsillitis, upper respiratory tract infections (including laryngitis and pharyngitis), cough, cold, and influenza are generally excluded.
- Neurological and Psychiatric Conditions: Conditions like epilepsy, hypertension, psychiatric or psychosomatic disorders, and unexplained fevers (pyrexia of unknown origin) are often excluded. Additionally, vector-borne diseases are typically not covered under domiciliary hospitalisation.
- Kidney and Liver Conditions: Disorders such as chronic nephritis, nephrotic syndrome, and various liver diseases are usually excluded.
- Digestive and Endocrine Disorders: Conditions like peptic ulcers, diarrhoea, dysenteries (including gastroenteritis), and endocrine issues such as diabetes mellitus and diabetes insipidus are typically not covered.
- Chronic Joint and Bone Disorders: Conditions like arthritis, gout, rheumatism, and problems associated with the spine or disc are typically not covered under domiciliary hospitalisation.
Note: This is a generic overview. Always check the specific terms and conditions of your insurance policy for more detailed information.
All that said, are looking for comprehensive domiciliary hospitalisation coverage and don’t know where to start from? Visit MyInsureBuddy Decoder Pages to explore plans that cover a wide range of treatments!
Domiciliary Hospitalisation vs. Home Care Treatment
Home care treatments are comparable to domiciliary treatments, as both involve receiving medical care at home for illnesses or injuries. However, unlike domiciliary treatments, which require specific conditions such as severe illness or injury preventing hospital admission or a lack of available hospital beds, home care treatments come with no such mandatory criteria. These treatments can be provided without the stringent requirements associated with domiciliary hospitalization. Here’s how both can be differentiated:
Characteristic | Domiciliary Treatment | Home Care Treatment Conditions for Coverage | The treatment shall be at home because of an acute illness/ injury or beds are not available in the hospital. | Treatment should be medically necessary and prescribed by a doctor, but it may also need pre-authorisation from the insurer. Claim | The claim can be made on both a cashless or a reimbursement basis. | Generally, these are claimed on a cashless basis, except in a few policies where they can be reimbursed. No. of treatments covered | This can be availed in case of any sickness or injury for which the conditions are met under the policy. | Certain policies cover a predefined list of treatments, such as dialysis, chemotherapy, or specialised care for conditions like dengue or hepatitis. Treatment Place | No location restriction, the treatment can be done at home in any city. | Treatment may be restricted only to metropolitan cities by some of the insurers.
Making a claim for domiciliary hospitalisation may seem daunting, but it’s simpler when you know the steps.
Domiciliary Hospitalisation Claim Process
To file a domiciliary hospitalisation claim under the health insurance policy follow the below-mentioned steps:
✅Doctor’s Assessment
A doctor examines the case and decides on domiciliary hospitalisation when necessary.
✅Treatment Plan Formulation
Based on the evaluation, the doctor creates a treatment plan, which might involve providing medical equipment or arranging nursing care.
✅Filing the Claim
The insurance company is notified by the family of the patient regarding the domiciliary treatment. A claim is then filed. The company informs of any further requirements, which have to be met by a well-wisher of the patient. The insured's family will submit all relevant documents to the insurance company.
✅Reviewing the Claim
The insurance company examines the claim with the documents submitted. If the disease and its treatment are included in the policy coverage, the insurance company approves the treatment. However, if the policy doesn't cover the disease or the treatment, the claim for domiciliary hospitalisation may be denied.
✅Approval of Claim
The insurance company pays for the cost of domiciliary treatment if the claim is accepted, up to the limit of coverage or the amount approved.
Please Note: These are general procedures for filing claims, and it may vary for different firms.
Curious to know how domiciliary hospitalisation could be beneficial to you? Keep scrolling and have your doubts cleared!
What are the Benefits of Domiciliary Hospitalisation?
The benefits of domiciliary hospitalisation are undeniable. Here’s an overview of the advantages that one might get:
- Treatment at Home: Domiciliary hospitalisation enables patients to receive medical care in the familiar surroundings of their home, offering a more relaxed and less stressful alternative to hospital stays, especially for those dealing with serious illnesses or injuries.
- Eliminates the Need for Hospital Transfers: For patients who are critically ill or injured and unable to be transported to a hospital, domiciliary treatment provides the essential care they need, without the additional risks or stress of moving them.
- Personalised Healthcare: Home treatment offers a personalised approach to care, allowing patients to receive dedicated attention from healthcare professionals, such as doctors or nurses, in the comfort of their own homes.
- Convenience for the Elderly: This type of care is particularly helpful for the elderly, as it eliminates the physical exertion and stress of hospital visits, especially when their health condition makes travelling difficult.
- Treatment Access During Shortages: Domiciliary hospitalisation ensures patients continue to get the care they need, even when hospital beds are scarce, providing timely treatment when facilities are limited.
While it’s an advantage to have domiciliary hospitalisation benefits, there are a few things that should be taken care of!
Essential Factors to Consider When Evaluating The Domiciliary Hospitalisation Benefit
Here are the points that should be kept in mind while evaluating the Domiciliary Hospitalisation Benefit of a health insurance policy:
✔️Verify Your Coverage
Check if your health insurance policy includes coverage for domiciliary hospitalisation, as this benefit is not always part of every plan. While many leading plans offer this benefit, some health insurance plans and Central Government Health Schemes like Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (PM-JAY) do not cover home-based treatments. It’s crucial to confirm the coverage specifics of your plan.
✔️Plans That Offer More Comprehensive Coverage
Most policies do not cover the cost of pre-hospitalisation and post-hospitalisation expenses, such as diagnostic procedures and observation charges unless otherwise stated. Some of the insurance companies like Aditya Birla Health and HDFC Ergo will be covering pre and post-hospitalisation costs on domiciliary treatments.
✔️Verify Coverage Limit
Certain policies set a limit on domiciliary treatment expenses. If the cost of treatment goes beyond this limit, you will need to cover the additional amount out of pocket.
✔️Minimal Duration Requirement
The treatment should be at least for three consecutive days as many policies have this condition to provide coverage.
✔️Select a Plan Which Includes All Treatments
There are a few plans, such as Chola MS Flexi Health, Manipal Cigna ProHealth Prime Active Plan, etc. in which a few treatments or diseases like respiratory problems, chronic diseases or even specific illnesses like diabetes, are not covered. Select the one that has coverage for every kind of domiciliary treatment. For example HDFC Ergo Optima Secure, Niva Bupa Aspire, Tata AIG MediCare Premier, etc.
✔️Understand Coverage Conditions
Domiciliary hospitalisation benefits can differ across insurance providers, making it vital to review the policy details carefully. For instance, some insurers may mandate a doctor’s certification to support the claim, and not meeting these conditions could lead to claim rejection. To avoid complications, choose a plan with fewer restrictions and thoroughly understand the terms and conditions for a hassle-free claims process.
✔️Exclusions for Alternative Therapies
Domiciliary hospitalisation coverage typically does not include treatments based on Ayurveda, Unani, homoeopathy, or other alternative medical practices.
Wrapping It Up!
Life’s uncertainties often catch us off guard, and health crisis and befell you at most unexpected times, requiring urgent care. Domiciliary hospitalisation can turn out to be the bridge between urgent medical needs and the unavailability of hospital care. It ensures receiving proper treatment in the comfort of your home, allowing you to recover surrounded by your family. This benefit highlights how health insurance can offer not just financial security but also peace of mind when it matters most.
But there's a catch: not all health insurance policies cover this, and those that do might come with conditions or restrictions. That’s why it’s essential to take a proactive approach. Review your policy today. Does it align with your family’s needs? If not, don’t wait for a crisis to highlight the gaps—explore policies that provide comprehensive domiciliary coverage.