What Type Of Costs Are Covered Under Health Insurance?

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 -

    Blood tests


    OPD consultations fees

    Diagnostic tests like ECG, EEG

    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 -

    Medical treatment expenses

    Room rent

    ICU charges

    Surgery cost

    Doctor consultation fees

    Oxygen supply

    Blood supply

    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




    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 -

    Regular check-up cost or follow up visits to your doctor

    Diagnostic tests such as colonoscopy, ECG, etc.

    Rehabilitation costs

    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.

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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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Wrapping Up!

Therefore, these are the expenses covered by Health Insurance. Before investing your money, be sure you are aware of what kind of coverage the policy offers. Take some time to read the policy wordings carefully - to avoid any unpleasant surprises later.

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We were fortunate enough to have selected SMC as our Health Insurance Broker for they have been very helpful in resolving our queries related to health insurance. I would like to cite two examples where SMC's role has been very crucial. One was when payment for cashless hospitalization was not coming through as the insurance company was taking undue longer time to approve the Hospital Bill. It was then I talked to Neha and it was she who through her contacts in the Insurance co. facilitated and expedited the approval for payment of hospital bill. Second was very recently when the Insurance co. had proposed a top up "Enhancer" policy for our existing policy. When I talked to Neha she immediately told me not to take this policy being offered without any medical test as it will not be beneficial to us and may create problem later on account of recent hospitalization. If I had I not consulted Neha, I would have into a big trouble with the insurance co. These two instances speak very high of sincere advice and timely help rendered by the SMC Staff, Ms. Neha Khanna which helped us a lot in time of need.Show More

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