Are Day Care Procedures Covered By Health Insurance?

Over the past few decades, medical science has advanced tremendously. Today, doctors can cure illnesses that once required days of hospitalisation in just a few hours. Health insurance plans in India have also changed their scope of coverage in response to these changes.

Imagine you are advised to undergo a colonoscopy in order to check the health of your colon. According to the doctor, the entire procedure shall take an hour or two and further adds that you can return home right away. However, you are unsure whether your health insurance would cover the procedure or not. Meanwhile, when you reach out to the hospital's insurance desk, you learn that your policy covers Day Care procedures as well.

It is evident that health insurance policies cover day care procedures as well. This article explains Day Care Treatment Coverage under Health Insurance in detail.

What Is A Day Care Procedure?

A day care treatment is one that is performed under general or local anaesthesia in a hospital or a day care centre, and takes less than 24 hours to complete. Insurers will cover day care procedures only if they are prescribed in writing by a doctor and deemed medically essential.

Day Care treatment usually includes the following procedures:

  • Piles / Fistula
  • Angiography
  • Dialysis
  • Cataract
  • Chemotherapy
  • Colonoscopy
  • Sinusitis
  • Eye surgery
  • Hydrocele
  • Appendectomy
  • Lithotripsy
  • Liver aspiration
  • Prostate
  • Radiotherapy
  • Sclerotherapy

This is just a partial list of some of the most common procedures. The actual list is much longer. Moreover, the types of treatments covered depend on the policy you choose.

exclusion of health insurance plans
Not Covered In Health Insurance
  1. Pre-existing Deceases for a Fixed Term
  2. Cosmetic Surgeries
  3. Injuries caused due to suicide attempts

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  • Do You Need To Compare The Number Of Day Care Procedures?

    Most health insurance companies mention the number of day care treatments they cover in their policy documents. Avoid looking at figures alone, as they can be deceiving.

  • What's the Reason?

    As you read through the list, you may notice that some insurers describe a procedure for a specific organ in a general sense, whereas others describe diseases and treatments in more detail.

    For instance, "Bone surgeries" is a broader category in some insurance policies. However, another insurer may segment this further into Ligament & Meniscus Tear Surgery, Orthopaedics and Trauma Surgery, Fracture and sutures on tendons, Dislocation Surgery, etc. It is likely that a detailed list will result in a greater number of treatments being included, but because of the level of detail, specific ailments may be overlooked.

Comparing Day Care Procedures Between Different Policies: How To Do It?

The process of reading through procedures and comparing them to another insurance company’s list is very difficult unless you are well versed in medical terminologies.

Plus, many leading insurers now offer plans without a list of day care procedures.They essentially say that all kinds of necessary hospitalizations will be covered without any limitations.

According to our analysis, this is the most effective choice when it comes to Day Care coverage. Choose a company that covers All Day Care Procedures rather than a narrowly defined list - so you are covered always, come what may.

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Day Care Procedures V/S OPD

Factors Day Care Treatment OPD Treatment
Definition You undergo surgery in an operation theatre under anaesthesia while being admitted in a hospital. The day-to-day medical consultations or small treatments such as dressing a wound or stitching a minor wound carried out under local anaesthesia.
Hospitalisation Hospitalisation spans less than 24 hours. Hospitalisation is not required.
Examples Cataract surgery, angiography, chemotherapy, etc. Health checkups, minor injuries, etc.

Claims Process For Day Care Procedures

The Day Care claims process is similar to regular health insurance claims since day care procedure coverage is part of the policy. You can make use of either reimbursement or cashless claims.

In order to be eligible for a cashless claim, you need to get treated in the network hospitals of the insurance company.

If you opt for a reimbursement claim, you can get treated in a hospital of your choice and pay all the medical expenses upfront. You can show the bills and all the necessary documents to the insurer - to get reimbursement.

Any pre-hospitalization and post-hospitalization expenses that you may incur are also covered by your health insurance plan. The T&Cs regarding coverage remain the same.

Pre-hospitalization Expenses - Costs related to tests or consultations before undergoing treatment or getting admitted to the hospital such as CT scan cost, blood test cost etc.

Post-hospitalization Expenses - Expenses that you incur after you are discharged from the hospital such as follow-up costs, diagnostic tests costs, physiotherapy costs etc.

Expenses such as doctor's fees, dental treatment, tests, and medical bills are also covered by some insurers. There are exceptions to this

Depending on the policy document, these expenses may also be subject to sub-limits. As coverage may vary from policy to policy, it is important to read the policy document carefully.

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Summing Up!

Health insurance policies not only cover major surgeries, treatments and hospital stays, but also day care procedures. If you are looking for ideal day care coverage, you should go for policies that cover a broad range of conditions rather than those that list specific procedures.

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