Critical treatment without hospital stay? Here’s why your medical expenses could still be covered

Day care procedures covered under health insurance policies vary as per the insurer

A 24-hour hospitalisation is often necessary for policyholders to file a claim under health insurance covers for reimbursement of treatment expenses.

To be sure, policies also pay for OPD (outpatient department) expenses and reimburse out-of-pocket expenses linked to doctor visits, medicines, diagnostic tests and so on.

Besides hospitalisation and OPD, however, there are several procedures that are covered under insurance, even if a patient is discharged the same day. Termed day care treatment, these complex procedures do not necessitate hospitalisation, thanks to advancements in medical technology.

These procedures work in favour of all stakeholders -- lower claim payout for insurance companies as hospital stay is not required, more comfort to the patient as she can recuperate at home and optimal bed occupancy management for hospitals.

Day Care vs OPD: Know the difference

Put simply, these are treatment procedures that would have required at least 24-hour hospitalisation, if not for medical innovations. In that sense, they differ from OPD expenses, which never require hospitalisation. For example, patients do not have to get hospitalisaed for simple diagnostic tests such as complete blood count, HbA1C and liver function tests. However, cataract surgery, the most commonly known day care procedure, did necessitate hospitalisation until the late 1980s.

Day care procedures covered

While medical procedures where 24-hour hospitalisation is dispensable are covered as day care treatment, your insurer will not cover all. You must refer to the specified list of day care procedures covered, as mentioned in your policy documents. Moreover, this is not a standard list across insurers. The number of admissible procedures and their descriptions might vary from company to company.

The Insurance Regulatory and Development Authority of India (IRDAI) -mandated standard policy Aarogya Sanjeevani, for example, covers 'all' day care procedures. These are defined as treatment or surgical procedures undertaken under local or general anaesthesia in a hospital/day care centre in less than 24 hours because of technological advancement. Such treatment modes would have required hospitalisation of over 24 hours otherwise.

Also read: How to estimate the right health insurance cover amount

Chemotherapy, dialysis commonly covered

All insurance companies put out a list of day care procedures that are covered in their policy documents and websites.

Some procedures that are typically covered by all companies include dialysis, radiation, chemotherapy, cataract surgery, hemorrhoid treatment and tonsillectomies. While these procedures do not require hospital stay, they will still be performed at hospitals, nursing homes or dedicated day care centres.

This apart, insurance policies also cover newer, modern treatment procedures such as oral chemotherapy and immunotherapy. Instead of being administered through the intravenous route, chemotherapy drugs are given to patients to be taken orally. Therefore, the patient-policyholder can get her expenses reimbursed despite not being hospitalised.

Be aware of sub-limits

Health insurance companies can impose a cap on the maximum expenses payable for certain day care procedures. For example, most policies pay for cataract expenses in the Rs 25,000-Rs 1 lakh range, depending on the product and variant.

This apart, if the day care procedures fall in the category of ‘modern treatment’ methods, again, caps could come into play. For example, a balloon sinuplasty might not be eligible for reimbursement of more than 10 percent of the sum insured. These caps, too, vary from company to company and health insurance products/variants.

While the procedures specified in the day care list could vary, certain treatments remain out of most health policies’s purview. For example, cosmetic treatment for eliminating moles and dental treatment (unless performed as part of reconstructive surgeries, after , say, accidents) will not be treated as day care procedures.

Also read: Have two health insurance policies? You can file claims under both

Not the key criterion for buying health policies

The number of procedures that can be performed without 24-hour hospitalisation has grown over the years, due to constant developments in the field of medicine. Health insurers, too, are increasingly expanding their lists of covered procedures, partly thanks to IRDAI’s nudge.

Broader coverage of day care procedures will work in favour of policyholders, but while picking a policy, focus more on the wordings and definitions rather than the number of procedures covered. For example, one health insurance plan could specify a long list of procedures related to nose that are covered; on the other hand, another policy could simply specify, say, five procedures, with the rest being covered under ‘other operations on the nose’. This does not mean that the latter's scope of coverage is restricted. In fact, it could be broader, ensuring wider insurance coverage for policyholders.