Day care procedures: How health insurers pay for major surgeries that don't need hospitalisation

Health insurance policies pay for cost of day care procedures

Health insurance policies primarily pay for treatment procedures where a patient is hospitalised for at least 24 hours.

In addition, if your policy also covers OPD (outpatient department) expenses, then your out-of-pocket expenses, such as doctor’s consultations and pharmacy bills, will be covered even if they are not linked to hospitalisation.

However, due to advancements in medical technology, many major and complex procedures do not need hospitalisation and insurance policies cover them as ‘day care’ treatment.

Such procedures ensure lower expenses for the insured and the insurance company by eliminating hospital stay, and provide more comfort to the patient as s/he can recuperate at home.

How are Day Care procedures different from OPD treatment?

Put simply, these are treatment procedures that would have required at least 24-hour hospitalisation were it not for technical advancements in the field of medicine.

Check your policy documents to ascertain if day care procedures are covered by your plan.

The Insurance Regulatory and Development Authority of India-mandated (IRDAI) 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. In that sense, they differ from OPD expenses, which never require hospitalisation.

Also read: How much health insurance do you need?

Whic day care procedures are commonly covered by policies?

All insurance companies put out a list of day care procedures that are covered in their policy documents and their websites. Some, like Aarogya Sanjeevani, simply state that all day care procedures are covered.

Common examples of day care procedures include dialysis, radiation, chemotherapy, cataract surgery, ligament tear surgery, hemorrhoid treatment and tonsillectomies. These procedures are usually carried out at hospitals or 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.

Will the procedures be covered with sub-limits?

There are no blanket sub-limits for day care procedures, but insurance companies can specify sub-limits for some. For example, most policies pay for cataract expenses in the region of Rs 25,000-Rs 1 lakh, depending on the product and variant.

In addition, if the day care procedures happen to be considered as ‘modern treatment’ methods, then sub-limits will apply. For example, a balloon sinuplasty might not be eligible for reimbursement of more than 10 percent of the sum insured. These caps, too, vary as per the non-life insurance company and health insurance product/variant.

Do note that cosmetic skin procedures are typically not covered under health insurance policies. Likewise, dental treatment, too, remains out of their purview, unless specifically covered as part of OPD or wellness packages.

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

Should the number of day care procedures covered be a criterion for choosing policies?

Thanks to rapid advancements in the field of medicine, the list of procedures that do not need hospitalisation has grown over the years. Likewise, the number of treatment procedures covered by health insurance policies has also increased.

While choosing a policy, however, rather than just the number of illnesses covered, it would be wiser to look at the definitions given. For example, one policy could mention a long list of procedures related to the 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.