How to claim pre- and post-hospitalisation expenses under health covers

Optimise your health insurance coverage by filing pre- and post-hospitalisation claims

Patients often incur multiple expenses before hospitalisation for a medical treatment, such as diagnostic tests, doctor consultations and medicines. Likewise, several expenses may arise post-hospitalisation, too.

However, most cashless claims under health insurance policies filed by hospitals on behalf of patients do not include these expenses. Hospitals typically only claim expenses incurred after admission for surgery or treatment, covering costs until discharge.

So, pre- and post-hospitalisation expenses are generally not part of the cashless claim process. In such cases, you can file a claim for reimbursement of such expenses separately with your insurance company.

Pre and post hospitalisation spends

Medical costs incurred before a patient is hospitalised for treatment are known as pre-hospitalisation expenses. Similarly, expenses incurred post discharge are referred to as post-hospitalisation expenses. Health insurance policies commonly cover such costs, typically over 45 to 90 days before and after discharge.

Insurance companies usually define the specific number of days for which pre-hospitalisation and post-hospitalisation expenses can be claimed, and these periods may vary depending on the insurer and the specific policy, plan, sum assured amount and so on. For instance, HDFC ERGO's Optima Secure health insurance policy and ICICI Lombard's Health AdvantEdge policy cover expenses incurred 60 days prior to hospitalisation and 180 days post discharge.

Tata AIG's MediCare health insurance policy offers different coverage periods under two plans: MediCare Premier and MediCare Protect.

Under MediCare Premier, medical expenses incurred 60 days before hospitalisation are covered. Post-hospitalisation coverage depends on the sum insured: for up to Rs 50 lakh, expenses incurred 90 days after discharge are covered; for sums above Rs 75 lakh, expenses incurred 200 days after discharge are covered.

Under MediCare Protect, medical expenses incurred 30 days before and 60 days after discharge are covered.

Also read: Explained: Pre and post-hospitalisation expenses in your health insurance policy

Awareness remains low

Despite the opportunity to maximise reimbursement of money spent on treatment, only a small percentage of policyholders typically file such claims. According to Kapil Mehta, co-founder, SecureNow, an insurance brokering firm, “the proportion of claimants (for pre and post hospitalisation) is quite low, at less than 25 percent."

Some other industry participants believe that the claim ratio is even lower. “By some industry estimates pre- and post-hospitalisation make up just about 3 percent of the total claim,” said Deepti Bhaskaran, head, strategic partnership and risk, Clinikk.com a healthtech start-up.

This is often due to a lack of awareness that these expenses are covered by health insurance policies. Many policyholders are only aware of the coverage for the actual hospitalisation period and may not realise that costs incurred for medical tests, consultations and treatments before being admitted to the hospital, as well as follow-up care and medications after discharge, are also eligible for reimbursement.

“Not many people file such claims primarily because these are small-ticket expenses spread over a period of time,” said Bhaskaran. On the other hand, some people may find the process of filing these additional claims cumbersome or complicated, leading them to forgo claiming these expenses. “Given the fact that these claims are reimbursement based and that many people don’t even maintain proper documents, such claims often do not get filed,” added Bhaskaran.

You should file claims for such expenses after the post-hospitalisation coverage period has ended, or once it is clear that no further expenses related to the treatment will be incurred. “You can submit these claims up to a month after the post-hospitalisation period is completed. This is sufficient time to put together the bills and file a reimbursement claim. You can take longer but it's best to do this fast, when you have a record of all documentation,” said Mehta.

Also read: How India’s health insurance preferences have changed over the last three years

Get the documentation right

To make a claim, you need to fill up the claim form and submit supporting documents, such as doctors’ consultation receipts, diagnostic test bills and so on. “You need to have the original OPD bills. These should have the supplier’s GST number and GST payments clearly listed. A doctor’s prescription is also necessary to link the expenses to the hospitalisation,” said Mehta. “A cancelled cheque tells the insurer where to send the reimbursement. Finally, you need to complete a claim form where you can reference the hospitalisation claim.”

Common mistakes policyholders should avoid

Before making a claim, it is important to understand a few key points. “First, the hospitalisation claims for which such expenses are claimed need to be admissible and second, these expenses should only be with regard to the cause of hospitalisation,” said Bhaskaran.

Remember, you cannot claim medical expenses unrelated to the reason for your hospitalisation. “If you are taking treatment for glaucoma but are hospitalised for an orthopaedic issue, then the glaucoma medicines will not be covered,” said Mehta.

Read your policy documents carefully to understand the duration of coverage and what is included or excluded by your policy. Finally, ensure that you preserve copies of original bills until the claim is settled.