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Domiciliary Hospitalisation

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

  • 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.
  • The hospital chosen doesn’t have the required facilities to treat the patient (lack of beds, equipment, etc.)

What is domiciliary treatment?

Treatment that patients take at home because of an illness or disease. This treatment is certified by medical professionals in hospitals. The expenses made can be claims if domiciliary hospitalization is included in the policy.

What are the diseases not covered under domiciliary hospitalization?

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

  • Asthma
  • Bronchitis
  • Chronic Nephritis and Nephrotic Syndrome
  • Diarrhea and all types of Dysenteries including Gatro-enterities
  • Diabetes Mellitus Insipidus
  • Epilepsy
  • Hypertension
  • Influenza, Cough and cold
  • All Psychiatric or Psychosomatic Disorders
  • Pyrexia of unknown origin for less than 10 days
  • Tonsillitis and Upper Respiratory Tract Infection including Laryngitis and Pharyngitis
  • Arthritis, Gout and Rheumatism

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Domiciliary hospitalization in group health insurance

There are two types

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

Some insurer don’t provide domiciliary hospitalization benefit in corporate mediclaim policy. In this case, employees taking domiciliary treatment cannot claim the expenses.

When you buy the policy, you can ask the insurer the charges for having domiciliary hospitalization included and add it.

Domiciliary claims - How does it work?

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. That is, expenses incurred before and after domiciliary hospitalization (Tests, x-ray etc.) are not covered.
  • 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, with group health insurance 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.

Read: How to calculate health insurance premium?

Domiciliary hospitalization and COVID-19

COVID-19 is one such disease that sometimes requires domiciliary hospitalization and is specifically categorized 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 recognized 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 ₹ 15,000 for the PSU insurers.

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