What Type of Costs are Covered Under Health Insurance?

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Monisha is a regular fitness and yoga practitioner. Since she was certain that no illness would affect her, she didn’t buy a health insurance policy . One fine morning, she suddenly developed severe pelvic pain along with fever. She visited a doctor who performed a CT scan and diagnosed her with cervical cancer. Her treatment included surgery and chemotherapy, costing around Rs 10 Lakhs (including ICU charges, room rent, etc). She had no choice but to use her savings and sell her car to take care of the costs.

If she had bought Health Insurance for herself by paying affordable premiums per year, she wouldn't have had to deal with such a financial strain in this emotionally draining situation.

Health insurance covers the costs for medical hospitalisation expenses arising out of an illness or injury. The first thing you should do before buying health insurance is to make sure you know what is covered under it - so you'll know what to expect in times of need.

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Coverage Provided Under Health Insurance

The following are the types of costs covered under Health Insurance-

  • Pre-Hospitalisation Costs

You may incur costs related to tests or consultations before undergoing treatment or getting admitted to the hospital called pre-hospitalizations costs. These costs are covered by Health Insurance. Most health insurance plans cover pre-hospitalization costs for 30 to 90 days.

Pre-hospitalization costs include -

  1. Blood tests
  2. X-rays
  3. OPD consultations fees
  4. Diagnostic tests like ECG, EEG
  5. Urine test, etc.

For example: Lekha has health insurance with a sum insured of Rs 10 lakhs. She gets mild chest pain, for which she consults a doctor. He advises her to undergo an ECG to check the condition of her heart. After examining the results, the doctor told her she had some complications and would require hospitalisation for 2-3 days. The ECG, any other tests, room rent, medicines, consultation fees, etc. shall be covered by her health insurance policy.

  • In-Patient Treatment Costs

Being admitted to a hospital comes with certain hospitalisation expenses. These may exceed your budget and drain your funds. However, Health Insurance covers hospitalisation costs. In order to be eligible for a claim, you must be hospitalised for at least 24 hours.

Here are some of the hospitalisation expenses covered by health insurance -

  1. Medical treatment expenses
  2. Room rent
  3. ICU charges
  4. Surgery cost
  5. Doctor consultation fees
  6. Oxygen supply
  7. Blood supply
  8. Medicine costs, and so on.

However, there is an exception to the rule. It will be discussed in the next point.

  • Day-Care Treatment Expenses

Some surgeries or treatments don't require you to stay overnight in the hospital (more than 24 hours). A health insurance policy covers these too.

These treatments include -

  • Gallbladder removal
  • Hernia
  • Chemotherapy
  • Cataract
  • Dialysis, etc
  • Post-Hospitalization Costs

Health insurance also covers the expenses that you incur after you are discharged from the hospital. Typically, these plans cover post-hospitalization costs for 60 and 180 days.

The following expenses are covered under this category -

  1. Regular check-up cost or follow up visits to your doctor
  2. Diagnostic tests such as colonoscopy, ECG, etc.
  3. Rehabilitation costs
  4. Physiotherapy sessions costs, and so on.

For example: Madhav has health insurance with a sum insured of Rs 5 lakhs. He underwent knee surgery and the surgery costs are approximately Rs 2 lakhs. To keep an eye on the surgical wound, the doctor scheduled fortnightly medical appointments. His health insurance shall cover the surgery costs and the follow-up consultation charges.

  • Organ Donor Hospitalisation

Many health insurance plans also cover the hospitalisation and surgical costs incurred by the organ donor during an organ transplant surgery. If this type of coverage is not provided under the plan, the expenses incurred by the organ donor during the period of hospital stay including the room charges, surgery costs, medicine costs, etc. shall need to be paid from your end.

  • Domiciliary Hospitalisation

If you are not in a condition to be moved to the hospital due to the illness or injury or if there are no hospital beds available, you can receive treatment in the comfort of your home. This is called Domiciliary Hospitalisation. Most health insurance plans cover all costs associated with such home care. A registered physician shall supervise the domiciliary treatment, and a paramedic or nurse shall be on hand all the time to monitor you.

For example, Vimal has a health insurance policy with a sum insured of Rs 5 lakhs. One morning, he was cleaning his house when he slipped and fell from the stairs. He broke his right leg and passed out. His brother called a doctor and explained the situation. The doctor advised him not to take Vimal to the hospital as any further movement could worsen the fracture. So, he arranged for the entire treatment to be administered at home. In this case, the complete domiciliary hospitalisation costs including the medications, shall be covered by Vimal's health insurance.