Coverage of Day Care Procedures under Health Insurance in India

Traditionally, only hospitalizations of more than 24-hours were covered under health insurance.

The advancement in medical science like laser treatments, laparoscopy have reduced hospitalization for many health conditions to less than 24 hours. In most cases, you are discharged on the same day you are admitted.

For instance, earlier patients were required to stay longer for hospitalization of cataracts, kidney stone surgeries, or heart surgery like angioplasty - these treatments, known as Day Care Treatments are now carried out within hours and the patient is ready to be discharged even on the same day. 

In this article, let's learn in detail about Day Care Treatment in Health Insurance.

What is a Day Care procedure?

In health insurance parlance, a Day Care Procedure is a medical procedure or surgery that previously required a prolonged hospital stay but due to advanced medical science can now be completed within 24 hours. A day care procedure will be covered under health insurance only if it is medically necessary and prescribed in writing by a medical practitioner.

Following are some of the common treatments that usually fall within the scope of the Day Care procedure:

• Appendectomy
• Piles / Fistula
• Angiography
• Dialysis
• Cataract
• Chemotherapy
• Colonoscopy
• Sinusitis
• Eye surgery
• Hydrocele
• Lithotripsy
• Liver aspiration
• Prostate
• Radiotherapy
• Sclerotherapy

The list above is just an example of the most common day care procedures, while the actual list, of course, is much longer. The number of day care treatments covered depends on the health insurance policy you select, which is covered later in this article.

Should you compare the number of day care procedures?

Most health insurance companies highlight the number of day care treatments covered under their policy brochure. Don’t just go after a number, as it can be misleading. Why? Let us explain.

Here is the comparison of day care procedures from leading insurance companies:

When you dig deeper into the list, you realize that some insurers mention a procedure for a particular organ in a broader sense, while some may have gone to micro-level details of mentioning each disease or treatment.

Here's an example: Some insurance providers may mention "eye surgeries" in their list, which is a wider definition. At the same time, another insurer may segregate this further into several surgeries of the eye such as cataract, incision of the cornea, incision of tear glands, operation of tear ducts, etc. As a result of a detailed list, the number of treatments covered will surely go up, but there is a good chance that because of the micro-detailing certain specific ailments/treatments can be left out.

How to compare day care procedures?

It is super difficult, unless you are a doctor, to read through 541 procedures and compare that with another insurer that lists 142 procedures. Here's what we feel, as you can see many leading Insurers now have plans which do not have a list of day care procedures. These insurers are basically saying that every kind of necessary hospitalization will be covered and not restricted by any list. In our view, this is the best coverage for Day Care amongst all plans. Other things being equal you must choose the company which has "All Day Care Procedures" covered instead of a specific list.

What is the difference between Day Care Procedures and OPD?

It is important to note that treatments are taken in OPD (Out-patient department) are not considered under day care procedures. You need to be admitted to the hospital for hospitalization to be called a day care procedure.

If you are admitted into a hospital room, you undergo surgery in an operation theatre under anesthesia, that will be considered daycare. If you are treated in the doctor’s room or around the doctor’s room or in the emergency room, even with local anesthesia, then it is considered an OPD expense.

For instance, dressing a wound, applying a plaster cast in the OPD area would be considered as an OPD treatment. Whereas a surgery carried out in an operation theatre and then a plaster cast applied will be considered as a day care procedure.

In most cases, the hospital bill will clearly mention such expenses as Emergency OPD or OPD expenses.

Claims process for Day Care procedures.

• The process of filing day care claims is similar to that of a regular health insurance claim as the day care procedure cover is an in-built policy feature. The insured can either avail of reimbursement or cashless hospitalization facilities at network hospitals of the insurance company.
• The provision for pre and post-hospitalization benefits remains the same.
• These plans also pay for doctor's fees, dental treatment, diagnostic tests, and medical bills. However, there can be some exceptions.
• These expenses are also subject to sub-limits mentioned in the policy document. It is advisable to go through the policy document carefully as coverage may vary from one policy to another.

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