Regarding day care surgery list
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 ???
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.
But there are some insurer that says all daycare treatment is covered like Star Health, Niva Bupa and Hdfc ergo even standard plans like Arogya Sanjeevni says all daycare treatment is covered and there is no list provided, we will cover everything but the PSU and the private insurer like Iffco Tokio will say only 120 daycare treatment is covered and suppose hospital advice me a daycare surgery which is not on the list we will not cover it
In that case, can I say to the hospital to admit me for 24 hrs and claim from the insurance company?
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.
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.
So don't you think if one has Arogya Sanjeevni policy with another comprehensive policy from another insurer it will be enough as Arogya sanjeevni says all other daycare treatment is covered and one more thing
Is in it Arogya Sanjeevni is standard policy and all insurers will have to offer the same policy (i.e same policy wording , same sum insured up to 10 lac)
then Why are some insurers have a different variant of the Arogya sanjeevni policy for eg Oriental have the Arogya policy up to 20 lac and also restricts day care procedures
Dear Dr Gauri,
Well actually once comprehensive policy should be enough to take care of day care procedure. Someone want's to carry a spare wheel in the boot..... sure one can.
IRDAI had allowed insurers to increase the sum insured limit. There are multiple guidelines on the same. My understanding is max sum insured allowed in 10 Lacs.
It will be difficult for me to comment on how does Oriental have a policy of 20 Lacs. Bajaj Allianz too offers a sum insured upto 25 Lacs. Intertestingly all insurer have a limit specified to room rent as max. Rs 5000/- per day while ICU limit is Rs 10000/- per day,however incase of Oriental for larger sum inusred this limit seems to have been increased.
It will be best to write an email to the Insurer to check for the higher cover.
Hope this was helpful
Thank you, Rohit
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