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Some might consider health insurance rigid, standardised, and expensive. However, with the advent of the internet, smartphones, and other tech-enabled operations, it’s productive to view health insurance as flexible, personalised, and affordable. For instance, did you know that your health insurance policy can cover medical expenses even if you are being treated at your home? This is possible due to domiciliary hospitalisation. Read ahead to know more about the Domiciliary Hospitalisation Cover in health insurance.
Understanding the domiciliary hospitalisation, meaning can be a bit tricky. It involves a situation where the medical expenses are covered by a health insurance policy even when the patient is not admitted to a hospital. Instead, the treatment is carried out at the patient’s residence. Here, the term hospitalisation alludes to a hospital-like situation being created at the patient’s residence for optimal medical care as per the disease/illness/injury.
It’s crucial to note that such a provision might only be applicable in case of:
being sanctioned by a doctor
specific reasons where the patient cannot be admitted to a hospital or other similar caregiving centres.
Domiciliary hospitalisation is not a common phenomenon. But it can be extremely useful for those who need it. Here’s how usually things pan out in the case of domiciliary hospitalisation if it is covered under the health insurance policy..
The insured patient cannot be admitted to a hospital due to a severe health condition or lack of accommodation at a hospital.
Doctors state that it’s best for the patient to be treated at their residence.
Care is provided to the patient at home as it would’ve been provided at a hospital.
Once the treatment is completed, the claim is settled as per the policy’s terms and conditions.
Here’s why it is vital to make sure your health insurance policy covers domiciliary treatment.
Goes beyond the hospitalisation-only insurance coverage.
Covers medical expenses in case of lack of bed availability at hospitals as experienced during the peak of the COVID-19 pandemic.
Coverage in case the insured patient cannot be moved to a medical facility due to the existing medical situation.
Offers peace of mind.
Domiciliary hospitalisation may or may not be a part of your basic health insurance policy. In some cases, it might be offered as an add-on. Therefore, you need to consider the following factors while purchasing health insurance.
Check the basic plan’s inclusions and exclusions to find out if domiciliary hospitalisation is included in the policy or not.
If the cover is not included, check if it can be purchased as an add-on.
Go through the cover’s features and benefits to make an informed choice.
Have a look if the cover comes with monetary limitations, especially when it comes to claiming settlement.
While considering such a cover, look at it from a worst-case scenario and not a preference. Often, getting admitted to a hospital might be the ideal solution from a medical care perspective.
Modern online health insurance policies might include domiciliary hospitalisation as a key feature. In case of buying health insurance offline, make sure to verify if such cover is a part of the policy or not. If not, then consider including it as it offers the following benefits.
Professional medical care at home.
No last-minute hassles in case hospitalisation is not possible.
Offers convenience for the insured patient and their family in case of emergencies.
Reduces the financial burden, which can be massive if the policy only covers hospitalisation.
Claim is settled as smoothly as it would have in case of hospitalisation.
If such a feature is bundled inside your health insurance policy, then it’s difficult to explicitly find out the cost (premium) of such an inclusion. On the other hand, if it is an add-on, then the payable premium to include it in your policy will be clearly mentioned.
The claim settlement amount might vary depending upon the severity of the insured patient’s disease/illness/injury. Also, the location (for example, the city of residence) can play a role in determining the total expenses. For example, the final bill for domiciliary hospitalisation is likely to be a lot more for a patient in Mumbai as compared to a patient in Raipur.
Note that there is a possibility of maximum capping with respect to the amount that can be claimed under such a provision. Also, the claim might be settled on a percentage basis with regard to the sum insured.
For example, considering the policy’s sum insured is INR 10,00,000 an amount up to 10% of the sum insured, which comes to INR 1,00,000 might be claimable under the domiciliary hospitalisation provision. There can be variance across insurers regarding such clauses. Thus, it’s best to clarify such terms and conditions at the time of policy purchase.
What is covered
What is not covered
The exact inclusions and terms of coverage will be mentioned in your insurance policy document. Here’s an example to illustrate the inclusions of this cover.
Forty-five-year-old IT consultant, Mr A shockingly collapses at his residence while working from home. This results in severe injury to his spine, due to which he cannot be moved from his home to a hospital. The reason for his collapse is attributed to a combination of low blood pressure and high stress.
Doctors analyse his specific condition and suggest domiciliary hospitalisation. The treatment goes well and Mr A recovers in a month. Post recovery, Mr A initiates an insurance claim by sharing all supporting documents and receives the settlement amount based on the policy’s terms and conditions.
Here’s why the claim was covered.
Mr A was covered by an insurance policy featuring domiciliary hospitalisation as an inclusion.
The doctors felt that domiciliary hospitalisation was the way ahead.
The reason for this type of care (severe injury) was covered by the policy.
The exact exclusions and terms of coverage will be mentioned in your insurance policy document. Here’s an example to illustrate the exclusions of this cover.
Mr B, a real estate agent, faced extreme stomach ache. Upon doctor consultation, it was found out that the pain was due to Gastroenteritis and suggested hospitalisation. Mr B was sceptical of visiting a hospital due to the fear of catching COVID-19. He checked out his insurance policy document and was pleased to read that it covered domiciliary hospitalisation.
Instead of following the doctor’s advice, Mr B opted for domiciliary hospitalisation. He was treated at home for three weeks, after which he recovered. Post recovery, he raised a claim but was shocked to know that the claim was rejected.
Here’s why the claim was not covered.
Although the policy covered domiciliary hospitalisation, the reason for it (Gastroenteritis) was an exclusion to the policy.
The doctor had advised hospitalisation and did not approve home care.
Proper documentation (for example, doctor’s written consent) was missing.
If you are covered under a holistic Group Medical Cover (GMC) offered by your organisation, then you might want to consider claiming under that policy. However, as is the case with an individual health policy, the GMC should also mention domiciliary hospitalisation as an inclusion.
If the GMC and your individual cover offer the same compensation, then you might consider claiming against a GMC so that you receive no-claim benefits while renewing the individual cover. Such benefits can either be an increase in sum insured or a decrease in payable premium.
To claim domiciliary hospitalisation in the case of Corporate Group Health insurance, you need to follow the process stated by the respective insurer. For example, if your ACKO-offered GMC covers domiciliary hospitalisation, you can raise a claim directly via the ACKO app.
Depending upon your insurer, you usually have the option of cashless claims or reimbursement claims.
Here, the insurer and the hospital have a tie-up for smooth claim settlement. You only have to pay the amount that’s not covered by your policy. In case of domiciliary hospitalisation, hospital-like situations will be recreated at the insured patient’s place of residence with the required medical equipment and settings. If allowed by the insurer, a cashless claim can be raised in such a scenario as well.
Here, the insured patient has to initiate a claim with the insurer after the treatment is completed. The claim needs to be supported by required documents such as doctor’s prescriptions, invoices, etc. Post claim initiation, the insurer will verify the application and settle the claim as per the policy’s terms and conditions.
Unlike a cashless claim, there’s no dependency on the insurer’s equation with the hospital. This type of claim involves settling the medical bills upfront from your pocket and getting the expenses reimbursed from the insurer.
Here’s a table showcasing the key differences between these two types of care provided to patients.
Points of difference
This is a specific terminology associated with insurance that refers to hospital-like treatment availed at home.
Here, residential care is used as generic terminology associated with availing prolonged medical care at one’s home.
Setting up medical equipment that supplies oxygen, checks the vitals, etc., in the patient’s home to treat a specific disease/illness/injury.
Hiring a full-time caregiver to look after an elderly patient’s basic medical needs.
Must be recommended by a doctor in writing.
May or may not be doctor recommended.
Can be covered if stated in the insurance policy.
Usually, not covered under health insurance.
This provision is not as per the patient’s preference.
This provision can be as per the patient’s preference.
To summarise, here are the points you need to remember.
Have a detailed look at your policy’s coverage and get your doubts resolved (if any) at the earliest with the insurer.
Merely noticing domiciliary hospitalisation as an inclusion will not be fruitful. The conditions under which it is an inclusion must also be looked at.
The doctor’s recommendation (in writing) for this type of hospitalisation is a must for smooth claim settlement.
This type of hospitalisation is not based on preference but rather considered as a provision in case of a worst-case scenario where the patient cannot be admitted to a hospital.
Domiciliary hospitalisation can prove to be extremely beneficial in certain cases and it’s good to consider this feature while selecting a health insurance plan. Assess your health, finances and make the decision of securing your future and reduce medical expenses with the help of added benefits such as this. Like the wise say, it’s better to have it and not need it, rather than excluding it and then having to need it.
All health insurance policies may not offer domiciliary hospitalisation as a part of the base policy. Some might require you to purchase it as an add-on. It is recommended to have a detailed look at the policy’s inclusions and exclusions before purchasing it.
Usually, there's a minimum requirement regarding such a cover with respect to the number of days/hours the insured patient needs to be placed in the hospital-like setting at home. In most cases, the requirement is for 72 hours. However, this number might vary across insurers.
Generally, AYUSH (Ayurveda, Yoga, and Naturopathy, Unani, Siddha and Homoeopathy) treatments are not covered under domiciliary hospitalisation. It is suggested to confirm the same with the insurer before buying the policy.