Inpatient Coverage in Health Insurance

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Aryan meets with a minor accident and fractures his right hand. He goes to the hospital, where the doctor informs him he has a slight bone fracture that will require a plaster cast. The doctor takes Aryan to the emergency room and puts the plaster cast on his hand. He also prescribes some medicines. All this amounts to Rs. 4000. Aryan contacts the insurer and informs them about the accident and the medical expenses. The insurer, however, tells Aryan that he’ll have to pay the expenses out of his pocket - because such expenses are not covered by health insurance.

To avoid anything like this from happening to you, it is important that you’re aware of all the aspects of your health insurance plan. One such important aspect is ‘Inpatient Care’.

Let’s learn in detail about inpatient care and the coverage of inpatient expenses under health insurance - in this article.

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What Is Inpatient Care?

Inpatient care is the healthcare that you get when you are admitted to a hospital to undergo a particular treatment or surgery.

When Will Your Health Insurance Cover Inpatient Care Expenses?

Inpatient expenses will be covered under health insurance only if the following 5 conditions are fulfilled-

  • Hospitalisation Should Be For At Least 24 Hours

    For inpatient care expenses to be covered under health insurance, you’re required to undergo a continuous hospitalisation of 24 hours or more.

    If you get hospitalised for instant treatment, or only for observation and monitoring purposes, or taking specific diagnostic tests - it won’t count as an inpatient hospitalisation.

    Note, hospitalisations less than 24 hours are covered under a separate heading called Day Care benefit.

    Example - Vansh is taken to the hospital after he suffers a heart attack. The doctor says a heart surgery will be required. So, Vansh is admitted to the hospital and the surgery is carried out the next day. After the surgery is completed, Vansh is discharged from the hospital. Here, Vansh was hospitalised for over 24 hours - so, this will be considered as an inpatient hospitalisation.

  • Hospitalisation Should Be ‘Medically Necessary’

    The insurance company will cover inpatient expenses only if the hospitalisation or the treatment you’re undergoing is ‘medically necessary’.

    Meaning, the treatment or hospitalisation must-

    Be required for the medical management of the illness or injury suffered.

    Not exceed the level of care necessary to provide safe, adequate, and appropriate medical care in scope, duration, or intensity.

    Have been recommended by a medical practitioner, who is unrelated to you.

    Conform to the professional standards widely accepted in international medical practice or by the medical community in India.

  • An Active Treatment Should Be Carried Out

    Health insurance will only pay when there’s an ongoing medical treatment while you are hospitalised. If the hospitalisation is just for diagnostic or monitoring procedures, the insurance company will not cover any expenses - even if the hospitalisation is more than 24 hours and recommended by a medical practitioner.

    For instance, Sanaya is taken to the hospital after she experiences symptoms like nausea, dizziness, shortness of breath, etc. The doctor suspects there is a blockage in her artery and advises her to get admitted. After she’s admitted, the doctor conducts some medical tests. There, however, is no treatment/ surgery carried out.

    After looking at the test results, the doctor says the dizziness and other symptoms were because of stress - there is no blockage in her artery. And then, she is discharged on the same day. Since there is no active treatment carried out - the insurance company will not cover the hospitalisation expenses.

  • Hospitalisation Should Be Prescribed By A Medical Practitioner

    Next, the hospitalisation or treatment that you undergo should be prescribed by a medical practitioner. If it is not prescribed by a medical practitioner, then health insurance won’t cover it.

    Some important things you must note here-

    The medical practitioner who’s prescribing the hospitalisation should not be your relative.

    The medical practitioner should give the prescription in writing.

    The hospital should seek the medical practitioner’s opinion for the hospitalisation.

  • The Cost Of Treatment/ Surgery Should Be Reasonable And Customary

    Lastly, if a hospital is overcharging for a treatment/ surgery, the insurer will not pay the overcharged amount.

    Basically, for every treatment or surgery, insurers look at the normal or acceptable range of payment that all the hospitals in a given area are charging. And, they then decide the reasonable and customary charge for that treatment or surgery.

    If you get admitted to a hospital that charges more than what other hospitals in that same geographical area are charging, the insurer can deny a full claim payment. They will only pay for charges that are reasonable and customary.

    Example - Rakesh has to undergo kidney surgery next month. He visits Hospital ‘A’ and finds out that the kidney surgery will cost him Rs. 3 Lakhs. The insurance company determines that the reasonable and customary amount for the kidney surgery is Rs. 2 Lakhs.

    Now, Rakesh undergoes the surgery in Hospital ‘A’ even after knowing that it is overcharging him. At the time of claim, the insurer will only pay Rs. 2 Lakhs, and Rakesh will have to pay the remaining amount, i.e., Rs. 1 Lakhs out of his pocket.

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Which Expenses Are Covered Under Inpatient Coverage?

Here are some types of expenses that are covered under inpatient coverage in health insurance-

  • Room Rent Costs

    Inpatient expenses include the room rent charges. Room rent is the per-day bed or room charges that the hospital will ask you to pay. There are different types of rooms in every hospital, like a single room, private room, AC room, deluxe room, twin sharing room, etc. The rent charges will be different for each room.

  • Room Boarding & Nursing Expenses

    Nursing and room boarding expenses include expenses that are incurred when you use the hospital room. Some examples of room boarding and nursing charges include the cost of cleaning, housekeeping, food, etc.

  • Fees Of The Medical Practitioners

    Fees of all medical practitioners, including physiotherapists, surgeons, primary doctors, treating doctors, etc. are also a part of inpatient expenses.

  • Cost Of Investigative / Diagnostic Tests

    Tests carried out to diagnose or monitor a medical condition, like an x-ray, a blood test, urine test, biopsy, etc. are covered under inpatient expenses.

  • Cost Of Prescribed Drugs And Medicines

    Inpatient expenses cover all costs of medicines and drugs prescribed by the treating medical practitioner. The prescribed medicines and drugs, however, should be related to the treatment you’re undergoing.

    For instance, if you undergo treatment for a kidney disease, health insurance will only cover the cost of medicines or drugs that are prescribed for the kidney disease. Any expenses incurred for medicines or drugs that are not related to kidney disease will not be covered under health insurance.

  • ICU Charges

    When you’re hospitalised, you may be shifted to an ICU either after completion of a major surgery or if you are extremely ill and require close monitoring. Intensive Care Unit (ICU) charges are covered under inpatient expenses too.

  • Cost Of Prosthetics And Implantable Devices

    An implantable device is a biomedical device that is placed in the body during surgery, whereas a prosthetic device is a device that is used to correct, replace, or support a body part or function of a body part.

    The cost of both prosthetic and implantable medical devices such as orthopaedic rods, screws, pins, artificial joints, etc. are covered under inpatient expenses.

Please note, this is just an indicative list. Besides the ones we’ve mentioned above, there will be other expenses that come under inpatient expenses in health insurance. So, ensure you go through the policy wordings before going ahead.

This brings us to the end of this article. Hope this article helped you gain enough clarity on coverage of inpatient expenses under health insurance.