Will Health Insurance cover Hospitalization treatment at home? | Domiciliary and Home care benefits in Health Insurance

During the second wave of Covid-19, the healthcare sector saw a shortage of hospital beds like never before. There was also a fear of re-infection - making it worrisome for people to undergo treatments at hospitals. As a result, a lot of people underwent hospitalization at home - so that they would receive the necessary care and treatment - but from the safety of their homes.

Covid-19 or not, there might be instances where you or someone in your family gets seriously ill or injured and would not be in a position to be carried to the hospital - and might have to undergo hospitalization at home. We’re sure you might have questions about whether your health insurance policy will cover the costs of such hospitalization - and under what conditions?

Benefits in Health Insurance that cover Home Treatment.

First things first, our Research Team scanned through 50+ health insurance policies and found that primarily home treatment is offered under two specific heads under health insurance -

Domiciliary Hospitalization Benefit
Home Care Treatment Benefit

Let’s find out what each of the benefits cover, and the fine print one should know.

What Is Domiciliary Hospitalization Benefit?

Domiciliary hospitalization includes treatments for illnesses or injuries that require immediate care and attention at a hospital but is actually taken at home because of either of the following conditions: -

The patient is severely ill or injured and cannot be moved to a hospital, or
There are no beds available in hospitals in the patients' locality.

Are Domiciliary Hospitalization Expenses Covered Under All Health Insurance policies?

Domiciliary hospitalization expenses are covered under some health insurance policies. You’ll have to go through your policy document and check - if it isn’t explicitly mentioned, your plan will not cover domiciliary treatments. However, if it is mentioned, the cover will be applicable if specific conditions are met.

General Conditions For Coverage Of Domiciliary Hospitalization

Here are some general conditions you should be aware of while buying health insurance with domiciliary cover in India.

👉 There could be a separate limit for Domiciliary Hospitalization

Your health insurance policy will mention a specific limit for domiciliary hospitalization expenses. So, if ever you undergo domiciliary treatment, your policy will only pay up to this limit. Any extra expenses you incur - you’ll have to pay them out of your pocket.

For instance, you’ve taken a health cover of INR 10 Lakh and the specified limit for domiciliary hospitalization expenses under your policy is INR 1 Lakh. Now, say you undergo a domiciliary treatment that costs you INR 1.5 Lakh. In such a case, your health insurance will offer domiciliary medical reimbursement of only INR 1 Lakh - the remaining INR 50,000 you’ll have to pay out of your pocket.

👉 Treatment should continue for 3 consecutive days

Most health insurance policies have a condition that the domiciliary hospitalization expenses will only be covered if you undergo the treatment at your home for at least three consecutive days.

Some plans that do not have this condition -

IFFCO Tokio (Family Health Protector Plan)
IFFCO Tokio (Individual Health Protector Plan)
Liberty General (Health Connect Plan)

👉 Pre and post-hospitalization expenses not covered

When you undergo a hospitalization at home, the expenses you incur before or after your hospitalization - such as tests and x-rays conducted for diagnostic and observation purposes, etc. may not be covered under the domiciliary benefit by most health insurance policies.

However, there are some plans that will cover pre and post-hospitalization expenses incurred for domiciliary treatments. They are -

Aditya Birla Health (Activ Assure Plan)
Aditya Birla Health (Activ Health Plan)
HDFC Ergo (Optima Restore Plan)

👉 Many treatments and diseases may not be covered.

There are insurance companies that do not provide the domiciliary benefit for the treatment of diabetes, diarrhea, respiratory disorders, etc. There are others that may not cover hospitalization at home for infertility or maternity purposes. Domiciliary hospitalization expenses incurred for alternative treatments like Ayurveda, Unani, Siddha, Homoeopathy, Naturopathy, etc. may also not be covered under some plans.

Please note: These conditions may vary across insurance companies. Ensure you go through your policy document before you opt for this benefit.

What Are Home Care Treatments? Does Private Health Insurance Cover Home Health Care Treatments?

Home care treatments are similar to domiciliary treatments - they refer to treatments for injuries or illnesses that are carried out at home. However, unlike domiciliary treatments, where you undergo hospitalization at home because you're severely ill / injured and can't be moved to the hospital, or because of unavailability of beds at the hospital - there are no mandatory conditions applicable under the home care treatment benefit.

Some policies that offer the home care treatment benefit -

HDFC Ergo Optima Secure
Max Bupa Health Reassure
Aditya Birla Activ Health

Out of these three insurance policies, Max Bupa Health Reassure will not cover pre and post-hospitalization expenses. Besides this, there are some additional conditions that need to be fulfilled if you want your health insurance to pay for your home care treatment.

Conditions For Coverage Of Home Care Treatments

While the conditions for home care treatment coverage may vary across insurance companies, here’s a quick rundown of some common conditions.

👉 Requirement of pre-authorization

You may have to get a pre-authorization from the insurance company beforehand to get the home care expenses covered.

👉 There could be a separate limit for Home Care Treatment benefit

The costs of such treatments may be covered under health insurance up to limits specified in the policy document.

👉 The treatment should be medically necessary

Home care treatment expenses will be covered under your health insurance only if the treatment is ‘medically necessary’. This means the treatment that you undergo -

Is required for the medical management of the illness or injury suffered.
Must not exceed the level of care necessary to provide safe, adequate, and appropriate medical care in scope, duration, or intensity.
Must have been recommended by a medical practitioner, who is not related to you.
Must conform to the professional standards widely accepted in international medical practice or by the medical community in India.

👉 Prescribed in writing

Your health insurance policy will only pay for the home care treatment expenses if you’re undergoing a treatment that is prescribed by the treating doctor in writing.

👉 Registered home healthcare service provider

It is mandatory that the service provider you’re getting the home care treatment from is a registered home health care provider.

👉 The treatment should otherwise require inpatient care

The treatment you’re undergoing at home should be such that it would otherwise require in-patient care at a hospital i.e. a continuous hospitalization of 24 hours or more. The claim, too, should be admissible under the inpatient treatment benefit of your health insurance policy.

👉 Maintain records of each day of home treatment

For each day of the home care treatment, records of the treatment administered will have to be maintained. And the records must be duly signed by the treating medical practitioner.

Please note: These conditions may vary across insurance companies. Ensure you go through your policy document before you opt for this benefit.

Domiciliary Treatments And Home Care Treatments: A Quick Comparison

	Domiciliary Treatment	Home care Treatment
Conditions for coverage	The treatment should be carried out at home because you are severely ill/ injured and can’t be moved to the hospital or because of the unavailability of beds at the hospital.	The treatment should be medically necessary and prescribed by the doctor in writing. You may also have to get a pre-authorization from the insurer for the said treatment.
Claim	You can claim this benefit on both - a cashless as well as a reimbursement basis.	You can claim this benefit only on a cashless basis under most policies. There, however, might be a few exceptions.
No. of treatments covered	This benefit can be availed for treatments of all injuries and illnesses as long as the conditions in your policy are met.	Some insurers have a specified list of treatments for which you can use this benefit. For instance, most insurers might only provide this benefit for dialysis, chemotherapy, dengue, hepatitis, etc. Your policy document will clearly list all such treatments - ensure you go through the list before opting for the benefit.
Place of treatment	Here, there is no restriction in terms of the location at which you undergo the domiciliary treatment.	Some insurers might have a condition that they will cover the costs only if the treatment is undergone in metropolitan cities.

This brings us to the end of the article. Hope you got a gist of the coverage of domiciliary and home care treatments under health insurance.

If you have any further questions about home care treatment benefit or health insurance with domiciliary cover in India, you can post them on the Beshak Insurance Forum and get answers from insurance experts!