Are Pre And Post-Hospitalisation Expenses Covered Under Health Insurance?

Hospitalisation costs are not restricted only to the hospital bill.

For a planned hospitalisation, you incur costs like doctor and specialist fees, charges for diagnostic tests like CT scans, X-rays, blood tests, etc., plus the huge cost of medicines. The treatment does not end when one gets discharged, since there is a recovery period - you will need periodic follow-ups, probably physiotherapy sessions, further diagnostic tests etc. This too costs a lot of money.

While you are aware that health insurance will cover your hospital bill, will it cover these costs incurred before and after hospitalisation? If so, under what conditions?

Let's take a look!

Pre-Hospitalisation Expenses

Medical expenses related to the hospitalisation treatment incurred before being admitted to a hospital are called pre-hospitalisation expenses. These include fees paid for doctor visits, cost of medicines, blood tests, urine tests, X-rays, and other diagnostic tests.

Pre-hospitalization expenses are covered by all health insurance policies in India. Depending on the insurer, these expenses can be claimed up to a certain number of days. Most health insurance policies cover expenses incurred up to 30-90 days before hospitalisation.

• Conditions Associated With Pre-Hospitalisation Expenses

  Health insurance coverage for pre-hospitalization expenses is generally subject to the following conditions. These conditions vary across insurers. Make sure you read your policy wordings carefully.

  Limit On Coverage

  Pre-hospitalization expenses are generally covered up to your base policy sum insured by most insurance companies. Some insurers might limit the amount that can be claimed for pre-hospitalization expenses.

  For instance, United India's Family Medicare policy will cover the pre-hospitalization expenses of up to 10% of the sum insured.

  Let's take a scenario - Dhanya has a health insurance plan of INR 10 Lakh. Her plan covers pre-hospitalization expenses up to INR 1,00,000 (10% of 10 Lakh). If her pre-hospitalization costs go beyond INR 1,00,000, she will need to pay the additional expenses herself.

  Inpatient Hospitalisation Is Compulsory

  Generally, the pre-hospitalization benefit can be claimed only for inpatient hospitalisation that is covered under health insurance. So if your hospital bill is not payable under your health insurance, then no other expense for the treatment would become payable.

  Limit Based On The Type Of Illness

  Although all health insurance policies in India cover pre-hospitalization costs, the coverage provided for the type of illnesses may vary. Hence, it is essential to read through your policy wordings to know the scope of coverage.

  For instance,

  Some insurers like Aditya Birla, Digit, Oriental, National, and Magma cover pre-hospitalization for psychiatric illnesses as well. However, some insurers don’t.

  Max Bupa covers pre-hospitalization physiotherapy expenses only if it is prescribed by the treating doctor.

Post-Hospitalisation Expenses

Costs that are incurred after you’re discharged from the hospital come under post-hospitalization expenses - diagnostic tests, blood tests, physiotherapy sessions, routine follow-up checkups after you undergo surgery or treatment, etc

Health insurance policies in India cover the post-hospitalisation expenses. Generally, health insurance covers hospital discharge expenses for about 60-180 days after you are discharged from the hospital. Depending on the insurer, this time frame may differ.

Conditions Associated With Post-Hospitalisation Expenses?

In order for your health insurance policy to cover post-hospitalization expenses, certain conditions must be met. Please note that these may vary from insurer to insurer.

• Post-Hospitalization Expenses Should Be Under The Same Treatment For Which The Insurer Has Approved The Claim

Only when the hospitalisation treatment is payable as per the policy conditions, then the expenses incurred for prescribed treatment after discharge will be payable under this policy.

For instance, Lalit was hospitalised for jaundice treatment. Now, his insurance policy will only cover the post-hospitalization expenses for jaundice. In the event he undergoes MRI for another medical condition, say for another health condition like a backache , his policy will not cover the costs.

• Limit On Coverage

A few insurers do not specify a post-hospitalization cap in the policy document, which means they cover the costs up to the base sum insured. Each insurer will have a different limit on the amount you can claim under the post-hospitalization benefit.

For instance, United India's Family Medicare policy covers post-hospitalization expenses to a maximum of 10% of the Sum Insured.

• Must Be Prescribed By Your Current Doctor

Only those post-hospitalization expenses prescribed by your treating physician will be covered under your policy.

Consider Lalit's example again. He was hospitalised for jaundice treatment. His health insurance covered all post-hospitalization expenses. A month after the discharge, he underwent a whole body checkup that was not prescribed by the doctor. His policy won't cover such costs.

• Some Policies Include Specific Benefits

Although all health insurance policies cover post-hospitalization expenses following an inpatient hospital stay, some policies also cover post-hospitalization expenses related to organ donations, psychiatric illnesses, and domiciliary hospitalisation.

Here are a few policies that provide these benefits:

1. National Insurance Mediclaim Plus Policy
2. Aditya Birla Active Health
3. Digit Health Care Plus
4. Magma One Health Policy
5. National insurance Parivar Mediclaim Plus Policy
6. Oriental Mediclaim Insurance Policy

Pre & Post-Hospitalisation Claims Process

These are the steps you need to follow to ensure a seamless claim experience -

• Once you are discharged from the hospital, you can claim both your pre and post-hospitalization expenses. You should try and submit all the documents within 30 days after your post-hospitalization period ends.
• To do so, collect all the bills, receipts of tests, original reports, and doctor prescriptions pertaining to your pre and post hospitalisation expenses.
• Duly fill the claim form with all the details of the expenses incurred by you. Include each and every expense, do not miss out on any.
• After filling the claim form, send it to the insurance company along with the bills, receipts of tests, reports and doctor's prescriptions. Ensure you get a detailed list of the documents from the insurance company that need to be submitted for the claim.
• You can send these documents to the insurer either via email, courier, or by directly visiting their branch, or you can even hand it over to your agent.

Note - Check with the insurer about how they prefer the documents to be sent to them. This may differ from insurer to insurer.

• Pre and post-hospitalisation expenses will only be covered if they are incurred within a specified timeframe -
• Pre-Hospitalisation: 30 to 90 days
• Post Hospitalisation: 60 to 180 days
• The insurer will not cover expenses incurred beyond this time limit mentioned by the insurer in the policy document.

Please note that the insurer will only cover expenses related to the same illness for which you were hospitalised.
 

Summing Up!

Pre and Post-hospitalisation expenses are covered by all health insurance policies. However, certain conditions must be met to be eligible for your claim to be approved. The limits and conditions may differ across insurance companies. Make sure you read your policy documents to know the extent of coverage and other clauses.