Coverage Of Domiciliary And Home Care Hospitalisation Under Health Insurance

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In certain situations, such as when your parents require hospitalisation for a medical condition or accidental injury and are too old to be taken to the hospital, you may choose to have them treated at home. Depending on the medical condition, your doctor may replicate the entire treatment regime at home under your watchful eye. Today, many hospitals offer such kinds of home treatment.

But, is home treatment covered by your health insurance policy? If yes, what are the conditions? Let’s see.


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Home Treatment Coverage Under Health Insurance

Two benefits under health insurance that cover home treatment -

  • Domiciliary Hospitalisation Benefit
  • Home Care Treatment Benefit

We'll discuss each of the benefits, along with their associated conditions.

  • Domiciliary Hospitalisation
    Domiciliary hospitalisation allows you to obtain medical treatment at home if your medical condition prevents you from seeking treatmeant at a hospital or medical facility.

A domiciliary hospitalisation may be necessary for the following two situations

The severity of a medical condition/injury preventing you from being moved to a hospital

The lack of availability of hospital beds

  • Domiciliary Hospitalisation Coverage Under Health Insurance
    Some health insurance policies cover domiciliary hospitalisation expenses. Domiciliary treatment won't be covered if it's not stated in your policy document.

If your policy covers these expenses, certain conditions must be met to be eligible for coverage.

These conditions may vary across insurers. Please read through your policy thoroughly before you go for this benefit.

Specific Limit For Domiciliary Hospitalisation
Health insurance policies have a limit for domiciliary hospitalisation expenses. You will be responsible for any extra expenses you incur.

For instance, Raghu has a health insurance policy with a sum insured of Rs 10 lakhs, and his policy stipulates a limit of Rs 1.2 lakhs for domiciliary hospitalisation expenses. Say he undergoes domiciliary treatment for his fractured arm and leg that costs him Rs 1.5 lakhs. His policy will cover Rs 1.2 lakhs of his domiciliary medical costs and he will be responsible for the remaining Rs 30,000.

Treatment Must Proceed For 3 Consecutive Days
A majority of the health insurance policies require you to undergo domiciliary hospitalisation for at least 3 consecutive days. Only then will the expenses be covered under the policy.

Some plans that do not have this condition -

  1. IFFCO Tokio (Family Health Protector Plan)
  2. IFFCO Tokio (Individual Health Protector Plan)
  3. Liberty General (Health Connect Plan)

For example, Aditya fractured his hip bone and was advised surgery and a 2-week bed rest with constant monitoring. Since he couldn’t be moved to the hospital, the treatment was carried out at his home. The treatment period was more than 3 days, and hence, the costs will be covered by his health insurance policy.

Pre And Post-Hospitalization Expenses Are Not Covered
Most health insurance policies do not cover expenses you incur before or after your hospitalisation, such as diagnostic tests - X-rays, CT scans taken for monitoring purposes.

Nevertheless, some plans do cover expenses incurred for domiciliary treatment before and after hospitalisation. Here are a few of them:

  1. Aditya Birla Health (Active Assure Plan)
  2. Aditya Birla Health (Active Health Plan)
  3. HDFC Ergo (Optima Restore Plan)

Let's recall Raghu's example. A month after the domiciliary treatment got over, the doctor advised him to undergo an X-ray and a CT scan to check his recovery. The costs for these diagnostic tests came to around Rs 5,000. Since his health insurance policy doesn't cover post-hospitalization expenses, he had to shoulder these expenses.

Some Treatments And Diseases Not Covered
Some insurance companies do not cover the domiciliary treatment of diabetes, diarrhoea, respiratory disorders, etc. and some insurance companies may not cover hospitalisation at home for infertility or maternity conditions. Also, there are some plans that don't cover domiciliary hospitalisation expenses for alternative treatments such as Ayurveda, Unani, Siddha, Homoeopathy, Naturopathy, etc.

  • Home Care Treatments
    Similar to domiciliary treatments, home care treatments are treatments for injuries and illnesses at home. As opposed to domiciliary treatment, where you undergo hospitalisation because of severe illness or injury and are unable to be moved to the hospital due to bed shortages, the home care treatment benefit does not have mandatory conditions.

Here are some policies offering home care treatment benefits

  1. HDFC Ergo Optima Secure
  2. Max Bupa Health Reassure
  3. Aditya Birla Activ Health
  • Conditions Associated Home Care Treatments Coverage

These are some common conditions you should be aware of. These conditions may vary across insurers. Hence, you go through your policy wording before you choose this benefit.

Pre-Authorization Is Compulsory
You need to get a pre-authorization in advance from your insurer. Pre-authorization is an initial approval of the treatment cost requested by the hospital from your insurer.

Specific Limit For The Home Care Treatment Benefit
Insurance companies may cover the costs of such treatments up to the limit stated in the policy.

Must Be Medically Necessary
The expenses of home care treatment will only be covered under your health insurance if the treatment is deemed 'medically necessary.

The treatment must meet certain conditions in order to be covered -

  1. Necessary for the medical management of the illness or injury.
  2. Must not exceed the level of care necessary to provide safe, adequate, and appropriate medical care in scope, duration, or intensity.
  3. A medical practitioner who is not related to you must recommend the treatment.
  4. Must meet the professional standards generally accepted by the Indian medical community or international medical practice.

Treatment Must Be Prescribed In Writing
A health insurer will only pay for your home care treatment if the treating doctor prescribes the treatment in question in writing.

Authorised Home Health Care Provider Is Mandatory
Getting home care treatment from a registered home health care provider is mandatory.

The Treatment Should Otherwise Call For Inpatient Care

In order to qualify for home care, your condition should otherwise necessitate inpatient care at the hospital, which means, a continuous hospital stay for 24 hours or more is mandatory. Your claim must also be approved under inpatient hospitalisation.

For example, Lalit was diagnosed with dengue and was advised hospitalisation. He requested his doctor to carry out the treatment at home. His health insurance will cover all of his treatment expenses.

Records Must Be Maintained
It will be necessary to keep records of the treatment administered every day of the home care treatment. The treating physician must sign the records.

  • A Quick Comparison: Domiciliary Treatments Vs Home Care Treatments

      Domiciliary Treatment Home care Treatment
    Coverage Condition The treatment should be carried out at home because you are severely ill/ injured and can’t be moved to the hospital or because of the unavailability of beds at the hospital. The doctor must prescribe the treatment in writing and it must be medically necessary. Pre-authorization from the insurer may also be required for the said treatment.
    Claim Option There is a cashless option as well as a reimbursement option available for this benefit. Most policies allow you to claim this benefit on a cashless basis. However, certain exceptions may apply.
    Number of treatments covered If the policy's conditions are met, you may use this benefit for treatments of all injuries and illnesses. Some insurers may limit the treatments for which you can use this benefit. Many insurers may only offer this benefit for conditions like dialysis, chemotherapy, dengue, and hepatitis.Your policy document will clearly list all such treatments - ensure you go through the list before opting for the benefit.
    Treatment Location As far as the location of the domiciliary treatment is concerned, there are no limitations. Certain insurers might only cover the costs of treatment if it is administered in a metropolitan area.

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Summing Up!

Choosing a health insurance plan that covers domiciliary hospitalisation and home health care treatment is necessary for mitigating health expenses. Since the future is uncertain and medical emergencies are unpredictable, such coverage may prove to be valuable in times of need. Read through your policy to ensure you are aware of the conditions and scope of this coverage.