Day Care Procedures in Group Health Insurance: What’s Covered & How to Raise Claims for Them

Ever had your employees ask you things like, "Does our group health insurance cover cataract surgery?" You're not alone, this is one of the most common questions HRs and employers hear! And if you're scratching your head about daycare treatments, don’t worry you’re definitely not the first.

The truth is, daycare treatments have become a real game-changer in healthcare. Thanks to modern technology, procedures that used to mean long hospital stays like Phacoemulsification for cataracts or Keyhole surgeries can now be done in a single day. Convenient, efficient, and perfect for busy employees, these treatments are rising in popularity for all the right reasons.

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A study by SecureNow reveals that approximately 29% of all health insurance claims are for day care procedures. Notably, over 50% of these claims have a settlement rate exceeding 80%. [1]

Recognizing this growing trend, the Insurance Regulatory and Development Authority of India (IRDAI) has mandated insurers to provide a transparent list of covered day care treatments.

This shift highlights the increasing importance of understanding the scope and coverage of health insurance policies, especially as day-care procedures become more commonplace. For HR professionals, this means ensuring that employee health insurance plans are comprehensive and up-to-date, offering clear coverage details for these frequently utilised medical services.

Day care treatment meaning

Day care treatment refers to medical procedures that do not require an overnight hospital stay. Typically, these treatments take less than 24 hours from admission to discharge. Thanks to modern medical technology, many conditions can now be treated this way, making healthcare more convenient and often less expensive.

For example, let's say you need cataract surgery. In the past, this might have required a hospital stay of several days. Now, with day care treatment, you can arrive at the hospital in the morning, have the surgery, and be back home by evening. This is not only more convenient for you but also reduces the overall cost of the procedure.

Day care treatment in group health insurance

Group insurance plans have evolved significantly to include coverage for day care treatments. Most Group Health Insurance plans now cover day care treatments. This coverage helps employees receive necessary medical care without worrying about hefty hospital bills or long stays.

What are day care procedures?

Day care procedures refer to medical treatments or surgeries that require hospitalization but are completed within 24 hours, thanks to advancements in medical technology. Unlike traditional inpatient treatments, these procedures do not necessitate an overnight stay. They span a wide range of specialties such as cataract surgery and corneal incision under eye procedures; ligament tear surgeries and fracture repairs in orthopedics; chemotherapy and radiotherapy in cancer care; and tonsillectomy and nasal sinus aspiration in ENT. These procedures are gaining relevance in employee health insurance plans, making it crucial for HR professionals to ensure clear coverage and claim understanding in their group policies.

Common day care procedures covered by insurance

Cataract surgery: A common eye surgery that involves removing the cloudy lens and replacing it with an artificial one.
Dialysis: A procedure to remove waste products and excess fluid from the blood when the kidneys are not functioning properly.
Chemotherapy: A treatment for cancer that uses drugs to kill cancer cells, often administered in a day care setting.
Sinus surgery: Surgical procedures aimed at relieving sinus issues, often performed endoscopically.
Eye treatments: Cataract surgery, removal of foreign bodies from the eye, and tear duct procedures.
Cancer care: Chemotherapy and radiotherapy treatments.
Kidney & urinary procedures: Dialysis, lithotripsy (kidney stone treatment), and hydrocele surgery.
ENT procedures: Tonsillectomy, septoplasty, sinusitis treatments, and ear-related surgeries.
Digestive system procedures: Colonoscopy, appendectomy, and liver aspiration.
Orthopedic procedures: Arthroscopy, fracture repairs, and other joint-related surgeries.

Key features of day care procedure coverage in group health insurance

Financial coverage: Many health insurance policies now cover these procedures
Pre- and post-hospitalization expenses: Coverage typically includes expenses incurred before and after the procedure, ensuring comprehensive financial protection for policyholders.
No 24-hour hospitalization requirement: Unlike traditional treatments, day care procedures are covered without the mandatory 24-hour hospital stay, making treatment faster and more convenient.

Importance of day care procedures in health insurance

Accessibility: Patients can access necessary treatments without lengthy hospital stays, promoting quicker recovery times.
Cost efficiency: Reduces the financial impact on patients who might otherwise face high out-of-pocket costs for treatments that do not require extended hospitalization.
Increased awareness: As more people become aware of these covered procedures, they can make informed decisions about their healthcare options.

How to claim day care treatments under group health insurance

Cashless claims: If the procedure is performed at a network hospital, the insurer directly settles the bill, minimizing financial stress.
Reimbursement option: If treated at a non-network facility, policyholders can submit necessary documents to claim reimbursement.

Why should HRs educate employees about day care procedures in health insurance?

Educating employees about day care procedures in group health insurance is crucial for both their financial well-being and the organization's overall benefits strategy. Here’s why:

Reduce out-of-pocket expenses
- Lack of awareness: Many employees pay out-of-pocket for medical treatments like cataract surgery or chemotherapy, unaware that these are covered under their group health insurance plans.
- Financial Relief: By understanding their coverage, employees can avoid unnecessary financial stress and make better use of their insurance benefits.
Improve employee satisfaction
- Enhanced benefits utilization: When employees know the full scope of their health insurance, including day care procedures, they feel more supported by their employer.
- Trust Building: Transparent communication about benefits fosters trust and loyalty among employees.
Promote financial wellness
- Cost Savings: Day care treatments are often expensive (e.g., dialysis or sinus surgery), but insurance coverage can significantly reduce these costs.
- Tax Benefits: Employees may also benefit from tax deductions on premiums paid for policies covering day care treatments.
Streamline claims process
- Avoid confusion: Educating employees about the claims process for day care procedures ensures smoother and faster reimbursements or cashless transactions.
- Proactive support: Employees can plan treatments at network hospitals to maximize their benefits.

How HRs can educate employees?

Conduct Workshops: Organize sessions explaining what day care procedures are, how they differ from inpatient care, and how to claim them.
Use Digital Tools: Share guides, videos, or FAQs through internal portals or apps for easy access. Use a modern benefits platform like Pazcare to ensure high visibility of covered procedures.
Collaborate with Insurers: Invite representatives from the insurance provider to answer employee questions directly.
Regular Updates: Provide reminders during annual open enrollment periods or when policy changes occur.

Conclusion

Day care treatments have redefined the scope of health insurance by including vital procedures that are completed within 24 hours—no overnight stay needed. As insurers continue to widen their coverage, employees can access timely medical care without worrying about out-of-pocket expenses. This is where HR teams step in by actively informing employees about these benefits, they help maximize the value of group health insurance plans.

Want to make your health benefits truly comprehensive? Partner with Pazcare and give your team seamless access to day care coverage, without the guesswork.

Key takeaways

Day care treatments expand coverage
Many insurance policies now include short-term medical procedures like cataract surgery, dialysis, and chemotherapy, reducing the need for extended hospital stays.
Smooth claim process
Employees can opt for cashless claims at network hospitals or get reimbursements for treatments at non-network facilities, ensuring flexibility in healthcare access.
HR’s Role in awareness
Educating employees about covered treatments helps them maximize benefits, reduce financial stress, and improve overall job satisfaction.

By staying informed and spreading awareness, HR teams can ensure that employees fully utilize their group health insurance benefits, promoting both financial wellness and job satisfaction.