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Are All Hospitals Covered under Health Insurance Policies?

Clueless over the technicalities of health insurance? Maximise your health coverage benefit with this comprehensive guide on hospitalisation.
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The technicalities of underwriting in health insurance policies can be overwhelming. Understanding their implications is not a piece of cake for the common man. As per the advice of a broker or agent, these terms can be simplified. You can also use the internet to resolve these queries. Inability to comprehend these terms would have adverse effects, especially, when it comes to the term hospitalisation.

So, What is Hospitalisation?

For a layman, it’s a place where a patient can stay, recuperate and get medical aid. As per different health insurance plans, a hospital is an institution that provides inpatient treatment and day care treatments of illnesses and/or injuries. The institution should be registered as a hospital with the local authorities under the Clinical Establishments (Registration and Regulation) Act, 2010 or under the Schedule of Section 56(1) of the Clinical Establishments (Registration and Regulation) Act, 2010.

Hospitals can also be defined as follows:

  1. An institution having at least 10 in-patient beds for a town with a population of less than 10 lakhs. For a population with more than 10 lakhs, 15 in-patient beds are mandatory.
  2. They should have qualified nursing staff 24×7. This applies for medical practitioners or doctors in charge too.
  3. A hospital should also have an operation theatre (OT). The completely equipped room is used for carrying out surgical operations.
  4. Daily records of patients should be maintained and made accessible to insurance companies.

What Should a Policy Holder Look for in Hospitals?

As a policy holder, before getting admitted to a hospital, do check for the following:

  • If the hospital meets the above criterion. If not, your claim would be denied. A local clinic with two beds is not the same as a hospital.
  • Go for network hospitals. All health insurance companies have a set of network hospitals listed. These are basically institutions with which they have tie-ups. Usually, they are listed under Preferred Provider Network. You would find their Third Party Administrators (TPA) working at such places. At these hospitals, cashless hospitalisation benefits are available too.
  • Even if you choose non-network hospitals, you may still be eligible for the claim. However, in such cases, reimbursement is done much later. You can get admitted first while the claim can be filed later. But, do remember to inform your insurance company of the same within 48 hours of admission.

Making Hospitalisation Claims

The major chunk of your health insurance claims is made at hospitals. So, now you are aware of how hospitals are defined; do make sure you pick the right one. But again, claims is not as easy as walking into the hospital. To be eligible for a hospitalisation claim you should:

  • Have received in-patient care at the hospital for more than 24 hours. In some cases, lesser hours are also qualified. They are listed as day care procedures in technical terms.
  • You can file for both pre- and post-hospitalisation expenses. Pre-hospital claims could be tests conducted at the hospital. Post-hospitalisation expenses are focussed on recuperation and follow-up checks. Usually, it covers costs incurred 30 days before hospitalisation and 60 days post discharge. But, it depends on the insurance company too.
  • Many domiciliary treatments are covered under hospitalisation too. Here, patient receives similar care at home.

But, each health insurance company has a different underwriting procedure. Being aware and informed can help save you from the hassles of a denied claim.

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