Are Pre and Post Hospitalization Expenses Covered Under Health Insurance in India?

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Are Pre and Post Hospitalization Expenses Covered Under Health Insurance in India?

Pre-hospitalization and post-hospitalization coverage in health insurance refers to the parts of the policy that pay for costs incurred before and after the insured patient is admitted to a hospital. Such a cover is referred to be wide-ranging in a health insurance policy since it includes specific pre-hospitalization and post-discharge fees in addition to covering costs spent while in the hospital.

These expenses can drain out your savings if not covered by your health insurance policy. Hence, pre-hospitalization and post-hospitalization coverages help to place a shield over your savings by offering financial support to settle medical bills during these difficult times.

What Are Pre-Hospitalization Expenses?

Pre-hospitalization charges are medical costs incurred before being admitted to a hospital. People typically contact their family doctor or a specialist when they are anxious. To arrive at a precise diagnosis, the doctor could recommend specific examinations and scans. The patient gets admitted to the hospital if the diagnosis is serious.

Usually, a patient undergoes several medical examinations before being admitted to the hospital. These tests, which reveal the patient’s medical status, include X-rays, CT scans, MRIs, Angiographies, blood-sugar tests, and others. Pre-hospitalization insurance will pay for these costs by the terms and circumstances of the plan.

What Are Post-Hospitalization Charges?

Post-hospitalization costs are those that the patient incurs (for treatment) after being released from the hospital. After a patient is hospitalized, treatment typically doesn’t finish when they are released from the hospital.            

Medication and care are part of the post-discharge healing process. Frequently scheduled medical consultations with professionals may also be necessary during this recovery period. This is when a policy that covers post-hospitalization costs can be useful.

Conditions For Coverage Of Pre-Hospitalization Expenses In Health Insurance

  • Coverage Limits

In general, up to your basic policy sum insured, the majority of insurance carriers will pay for pre-hospitalization costs. Some insurers, nevertheless, can place a cap on how much you can deduct for pre-hospitalization costs. For instance, the Family Medicare plan from United India will pay up to 10% of the insured amount toward pre-hospitalization costs.

Therefore, pre-hospitalization costs up to INR 50,000 will be covered if you have a health insurance plan worth INR 5 lakh (10 percent of 5 Lakh). You will be responsible for covering any pre-hospitalization expenses that exceed INR 50,000.

  • Inpatient Hospitality Mandatory

The pre-hospitalization benefit in your policy can only be used if you are admitted to the hospital as an inpatient for additional treatment, which requires that you stay there for longer than 24 hours nonstop.

  • Restrictions Based On Types Of Illness

There may be limitations based on the ailments for which the policy will offer the pre-hospitalization benefit, even though all health insurance policies in India cover pre-hospitalization costs. So, before you decide on a plan, make sure you read the policy statement

  • Can Only Be Claimed On A Reimbursement Basis

Some insurance plans, such as the Niva Bupa Reassure and Aditya Birla Health Activ plan, allow you to claim post-hospitalization costs exclusively on a reimbursement basis, which means you must pay the costs out of pocket before filing a claim with the insurance provider.

Conditions For Coverage Of Post-Hospitalization Expenses In Health Insurance

There are a few requirements that must be completed for post-hospitalization costs to be paid by your health insurance plan:

  • Costs Should Be Related To The Same Illness For Which You Were Specialized

Only the same condition or treatment for which you were hospitalized is eligible for utilization of the post-hospitalization benefit under your health insurance.

Say you have dengue and were admitted to the hospital. Only the costs associated with dengue post-hospitalization will now be paid by your insurance. Your insurance will not pay the price of any tests you have if they are for another medical problem, like thyroid.

  • Coverage Limits

The limit up to which you can claim under the post-hospitalization benefit will vary from insurer to insurer. Some insurers don’t specify any limit in the policy document, that is, they cover the post-hospitalization costs up to your base sum insured. However, some insurers mention a limit.

  •  Claim Must Be Under Inpatient Benefit

Only if you are hospitalized for a continuous period of 24 hours or more and the insurance provider has authorized a claim under the inpatient benefit under your health insurance plan will post-hospitalization costs be covered.

  • Can Only Be Claimed On A Reimbursement Basis

Post-hospitalization charges can only be claimed under some policies, such as the Niva Bupa Reassure and Aditya Birla Health Activ plan, on a reimbursement basis, meaning you must pay the costs out of pocket before filing a claim with the insurance provider.

  • Should Be Prescribed By The Treating Doctor

Only the post-hospitalization charges under your coverage that are recommended by the treating physician will be covered by the insurance provider. For instance, suppose you had heart surgery and, a month after being released from the hospital, you have a cardiac x-ray, even though the surgeon did not order it. Your policy won’t provide coverage for these expenses.