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Regarding day care surgery list

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10 Feb, 2022 by  Dr. Gauri Agrawal

Almost all insurer companies have a list of day care list that they cover, some say they will cover all day care surgery but suppose a day care surgery not on list & we say the hospital to admit it for 24 hours and perform the surgery will we able to claim the procedure under health plan

remind you that this surgery can be performed under day care but due to day care list limitation we say the hospital to admit us full 24 hours ???

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16 Feb, 2022

Hi Dr Gauri,


Earlier a limited list was there but now many more procedures are included and it is getting updated frequently.


Just a suggestion, most day care surgeries/procedures are planned hospitalizations. You can get in touch with your Insurer/TPA well in advance and seek their guidance to avoid any future complication.

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16 Feb, 2022
Dr. Gauri Agrawal
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16 Feb, 2022
Insurance Sandesh

IRDAI defines day care procedure as follows.

"Day Care treatment means the medical treatment and/or surgical procedure which is – (i). Undertaken under General or Local Anesthesia in a hospital/day care centre in less than 24 hrs because of technological and (ii) which would have otherwise required a hospitalisation of more than 24 hours. Treatment normally taken on an out-patient basis is not included in the scope of this definition."


Based on the above definition it can be clearly concluded that the claim is payable under day care list if the procedure performed meets above 2 criteria irrespective of whether the treatment is listed under the day care list or not.

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16 Feb, 2022
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Dear Dr Gauri,


There will not be a clear answer to this. Health Insurance has some grey areas and lot would depend on what led to over 24 hrs of hospitalisation incase of daycare. At first instance the insurer is likely to reject the claim as the procedure was not covered. However if the surgery led to any complication that required policy holder to be hospitalised then insurer is likely to approve, but they are likely to a proper investigation for the same. There could also be a case where insurer would intitially reject cashless and request policy holder to apply for reimbursement claim till the time they carry investigation.


In a nut shell the case papers are most important document. Hope this helps.


Regards

Rohit Dhingra

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17 Feb, 2022
Dr. Gauri Agrawal
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17 Feb, 2022
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17 Feb, 2022
Dr. Gauri Agrawal
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