Yes, diagnostic tests such as X-ray, MRI, CT Scan, Ultrasound, Blood Tests, ECG, and Biopsy are covered under your health insurance policy, but on two conditions: the test must be medically necessary and fall under the coverage of your health insurance policy. In general, the diagnostic test is covered when it relates to any of the following:
Admissible Hospitalisation
Admissible Day Care Treatment
Admissible Pre-Hospitalisation Expense
Admissible Post-Hospitalisation Expense
Admissible OPD Benefit
Preventive Health Check-up Benefit
A test, which is not related to any one of the above and is not part of any of the other benefits of your health insurance policy, is usually not covered.
When will health insurance cover diagnostic expenses?
Health insurance will cover diagnostic expenses if the test is needed for diagnosis or treatment of an illness or injury that the health insurer recognises as a payable claim.
Situation | Is a diagnostic test usually covered? |
|---|---|
Test done during hospitalisation | Usually yes |
Test done before hospitalisation | Usually yes, as a pre-hospitalisation expense |
Test done after discharge | Usually yes, as a post-hospitalisation expense |
Test done under daycare treatment | Usually yes |
OPD test without hospitalisation | Only if your policy has OPD cover |
Annual preventive check-up | Only if your policy has this benefit |
What kinds of tests qualify for health insurance coverage?
There are various kinds of diagnostic tests that health insurance can pay for when they are medically required. Some of the most common tests include:
Diagnostic test | Common reason for the test |
|---|---|
X-ray | Fracture, chest infection, injury, pre-surgery assessment |
MRI | Spine, brain, ligament, joint, nerve or soft-tissue evaluation |
Ultrasound | Abdominal, pelvic, kidney, liver, gall bladder, thyroid or pregnancy-related evaluation |
CT scan | Head injury, stroke evaluation, infection, tumour assessment, trauma |
Blood tests and pathology | Infection, fever, surgery work-up, chronic disease monitoring |
When does health insurance not cover diagnostic charges?
Not all diagnostic expenses are covered under health insurance. Generally, your claims will not get approval if there is no connection between the test and treatment procedure, or your plan doesn't offer that particular benefit.
Your routine diagnosis, which is done without any symptoms or treatment, is not covered in your health insurance policy.
Tests done either before or after your hospitalisation are also not covered by the insurance. Each insurance company offers a different number of days for pre and post-hospitalisation.
Missing documents can delay or even lead to rejection of your claim. Make sure you submit the doctor's prescription, diagnostic reports, invoices, payment receipts, and the claim form.
Diagnostic tests done in OPD are not covered if there is no OPD benefit in your health plan.
Explore our complete guide to OPD coverage in health insurance to understand its benefits, limits, and claim process.
How does a health insurance claim for diagnostic tests work?
Under cashless hospitalisation, the estimated treatment cost is communicated to the insurer or TPA by the hospital, and the insurer settles the admissible charges directly with the network hospital. With respect to reimbursement, the individual pays for the diagnostic test and then files the relevant documentation to get the admissible amount from the insurer.
Claim route | How the diagnostic charges are settled | How much will you pay first? | Documents usually needed |
|---|---|---|---|
Cashless hospitalisation | In-hospital diagnostic charges are included in the hospital bill sent to the insurer. | You pay only non-admissible charges, deductibles, copayments, and excess amounts if applicable. | Hospital estimate, medical records, discharge summary, reports and final bill. |
Reimbursement hospitalisation | You pay the hospital and diagnostic bills first, then claim eligible charges. | You pay the full bill first. | Claim form, prescription, reports, invoices, payment receipts, discharge summary and hospital bills. |
OPD reimbursement | You submit outpatient consultation and diagnostic bills if OPD diagnostics are covered. | You pay the full test cost first. | OPD prescription, diagnostic report, tax invoice, payment proof and policy-specific documents. |
Want to understand reimbursement claims better? Read our complete guide to reimbursement in health insurance.
How to file a health insurance claim for diagnostic tests?
Identify the benefit applicable to your case
Go through your policy and identify the benefit under which you're making the claim. It could be hospitalisation-related diagnostic tests, day care, pre-hospitalisation, post-hospitalisation, outpatient department (OPD), and preventive health check-ups.
Collect all your documents
You will need your doctor’s prescription, your diagnosis, your billing details, and, if your claim relates to hospitalisation, your discharge summary as well.
File your claim
If you are filing for a cashless claim, the bills and your medical documents will automatically be sent to your insurer by the network hospital. In case of reimbursement claims, you will need to send all your documents to your insurance company.
Verify your claim settlement
In the process of claim settlement, if there is any reduction made to your diagnostic costs, the reasons must be clearly stated by your insurer.
Key Takeaways
Diagnostic tests like X-rays, MRIs, Ultrasound scans, and blood tests may be reimbursed under health insurance as long as they are part of a reimbursable treatment or fall under the OPD or preventive health check-up benefit of your health insurance plan.
Standalone diagnostic tests are generally not reimbursed, except in cases where your plan offers OPD diagnostic cover or a preventive health check-up benefit.
The prescription of your physician alone cannot ensure reimbursement of a diagnostic test; in addition, it should also fulfil the terms and conditions of your health insurance plan.
In the end, your reimbursement amount will also depend on your health insurance plan.
Frequently asked questions
Yes, an MRI is generally covered if recommended by your doctor as part of a covered treatment like hospitalisation, day care treatment, pre- or post-hospitalisation care, or OPD benefit, which is part of your health insurance plan.
Yes, an X-ray is normally covered if it is required as part of a covered treatment. However, a routine X-ray conducted as a matter of general check-up for fitness or employment will not be covered unless your health insurance plan covers this benefit.
Yes, if the ultrasound is necessary for the diagnosis and/or treatment of a covered disease or injury, then it will be covered.
Yes. Blood tests may be covered if they fall under a covered benefit in your health insurance policy, such as hospitalisation, OPD diagnostics, or a preventive health check-up.
Yes, only if your health plan provides coverage for OPD diagnosis or preventive health check-up. Otherwise, separate diagnostic tests are usually not covered under the plan.
About the authors
Neviya Laishram
Written by · Senior Editor – Health, Life and Group Health Insurance Content at ACKOWith a journalism background, she brings 9 years of experience in strategising and editing health, life, and group health insurance content. Having written for magazines and digital publications, she combines research and editorial expertise to create credible, useful content for readers.
Dr Nitin Kumar Gupta
Reviewed by · SVP – Health Underwriting & Claims at ACKO General InsuranceWith 20+ years of experience in digital transformation and growth, he is a leader specialising in health, life, accident, and disability insurance. Backed by an MBBS degree and insurance designations (FLMI, FALU, FLHC, ACS, ARA), he combines expertise with leadership.
