Domiciliary Hospitalization - Health Insurance and Claim

What is domiciliary hospitalization?

Domiciliary hospitalization is a case where a patient has an illness or disease that requires hospitalization but gets it from home because of the below reasons

1. The medical condition is such that the patient cannot be moved to the hospital and it is best to treat immediately from home or is having a prolonged treatment for recovery.
2. The hospital chosen doesn’t have the required facilities to treat the patient (lack of beds, equipment, etc.)

Domiciliary hospitalization in health insurance

There are two types

1. Domiciliary hospitalization is included by default in a few health insurance policies.
2. Domiciliary hospitalization is bought as a rider to the base plan

Rider in insurance means an extra or add-on cover bought over the base plan with an additional premium.

Who gives domiciliary hospitalization by default?

Here are a few insurers who give domiciliary hospitalization by default in some of their covers.

1. Edelweiss general Insurance
2. Tata AIG

However, it is important to check with your insurer if domiciliary hospitalization is included or excluded.

How does insurance claiming work in domiciliary hospitalization?

Here are some pointers that will help you understand claim process under domiciliary hospitalization.

• Pre and post-hospitalization expenses are not covered in domiciliary hospitalization
• Treatment exceeds more than 3 days and generally requires a doctor to treat.
• Domiciliary hospitalization comes with a waiting period that differs with different insurers. You can file a claim when the waiting period is over. However, if you have group health insurance (insurance given by your employer) you may not have a waiting period.
• Check with your insurer on the cap of the domiciliary hospitalization. For example, if you have a health insurance cover of 3 lakhs and a cap on domiciliary hospitalization is 10%, then you can claim 30,000 for domiciliary hospitalization expenses.
• To claim you need to have the bills and the treating doctor’s letter to the insurance company (TPA), stating the reason for domiciliary hospitalization.

Also read: How to calculate health insurance premium?

What are the diseases not covered under domiciliary hospitalization?

The following diseases cannot be claimed under domiciliary hospitalization according to IRDA.

1. Asthma
2. Bronchitis;
3. Chronic Nephritis and Nephrotic Syndrome;
4. Diarrhoea and all types of Dysenteries including Gatro-enterities;
5. Diabetes Mellitus Insipidus;
6. Epilepsy;
7. Hypertension;
8. Influenza, Cough and cold;
9. All Psychiatric or Psychosomatic Disorders;
10. Pyrexia of unknown origin for less than 10 days;
11. Tonsillitis and Upper Respiratory Tract Infection including Laryngitis and Pharyngitis
12. Arthritis, Gout and Rheumatism

Domiciliary hospitalization and COVID-19

COVID-19 is one such disease that sometimes requires domiciliary hospitalization and is specifically categorised as Home Quarantine. Here’s what Insurance Regulatory and Development Authority (IRDA) tells about domiciliary hospitalization for COVID-19.

• You need confirmation of COVID-19 by any lab recognised by ICMR. (Click here to access the list of labs for COVID-19 tests by ICMR)
• Any Medical Expenses payable shall not in aggregate exceed 50% of the annual sum insured.
• The domiciliary hospitalization happens for not more than 14 days.
• Needs to be medically necessary and must be on the written advice of a doctor followed by observation chart and medicine bills

In general,  the expenses for domiciliary hospitalization for COVID-19  is capped at a maximum of INR 15,000 for the PSU insurers.

If you are looking for group health insurance for your team with domiciliary hospitalization, get in touch with Pazcare.

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