When you get diagnosed with a disease or meet with an accident and need to undergo treatment or surgery - there are not just hospitalization costs involved. You’ll also have to incur expenses for conducting tests to know the severity of the injury or the illness. Then, after you’re discharged from the hospital, you might have to visit the doctor for check-ups or undergo physiotherapy sessions for faster recovery or some tests for monitoring purposes. 

Will your health insurance policy cover all these costs you incur prior to and after a hospitalization? If yes, under what conditions? And how to claim post hospitalization expenses and pre hospitalization expenses under health insurance? 

Let's find out. 

What are Pre-hospitalisation Expenses? Are they covered under Health Insurance?

All expenses that you incur prior to any hospitalization come under pre-hospitalization expenses. These include costs of tests conducted for diagnostic purposes like blood tests, urine tests, x-rays, etc. 

In India, all health insurance policies cover pre-hospitalization expenses. The number of days up to which you can claim for the pre-hospitalization expenses will vary from insurer to insurer. Normally, expenses up to 30 to 90 days before the hospitalisation are covered under health insurance.

Conditions for Coverage of Pre-hospitalisation Expenses in Health Insurance

Here are some general conditions around coverage of pre-hospitalization expenses in health insurance. 

👉 Coverage limits 

Generally, most insurance companies cover the pre-hospitalization expense up to your base policy sum insured. However, a few insurers might impose a specific limit up to which you can claim pre-hospitalization expenses. For instance, United India's Family Medicare policy will cover the pre-hospitalization expenses of up to 10% of the sum insured.

So, if you have a health insurance plan of INR 5 Lakh, it will cover pre-hospitalization expenses up to INR 50,000 (10% of 5 Lakh). If your pre-hospitalization costs are above INR 50,000 - you will have to pay for them out of your pocket.

👉 Inpatient hospitalization mandatory

You can claim the pre-hospitalization benefit in your policy only if you undergo an inpatient hospitalization for further treatment, meaning, you're admitted to the hospital for more than 24 hours continuously.

👉 Restrictions based on types of illnesses

While all health insurance policies in India cover pre-hospitalization expenses, there might be restrictions based on the types of illnesses for which the policy will provide the pre-hospitalization benefit. So, ensure you go through the policy document before you finalize a plan. 

Insurers like Aditya Birla, Digit, Oriental, National, and Magma cover pre-hospitalization for psychiatric illnesses as well. However, other insurers don't cover pre-hospitalization costs of psychiatric illnesses at all. Further, Max Bupa covers pre-hospitalization physiotherapy expenses if it is prescribed by the treating doctor. 

Please note: The above conditions and limits may vary across insurance companies. Ensure you go through your policy documents before you opt for this benefit.

What are Post-hospitalisation Expenses? Are they covered under Health Insurance?

Costs that are incurred after you’re discharged from the hospital come under post-hospitalization expenses. For instance, costs of tests done for observation or monitoring purposes, physiotherapy sessions, routine follow-up checkups after you undergo surgery or treatment, etc.

Post-hospitalization expenses are covered under all health insurance policies in India. Generally, post-hospitalization expenses up to 60 to 180 days after being discharged from the hospital are covered under health insurance. This number, however, might vary from insurer to insurer.

Conditions for Coverage of Post-hospitalisation Expenses in Health Insurance

For Post-hospitalisation expenses to be covered under your health insurance policy, there are certain conditions that need to be met. 

👉 Costs should be related to the same illness for which you were hospitalized

You can use the post-hospitalization benefit under your health insurance only for the same illness or treatment for which you were hospitalized. 

Say you underwent hospitalization for dengue. Now, only the post-hospitalization expenses of dengue will be covered by your policy. If you undergo tests for some other medical condition, say thyroid, then the costs won't be covered under your policy.

👉 Coverage limits

The limit up to which you can claim under the post-hospitalization benefit will vary from insurer to insurer. Some insurers don't specify any limit in the policy document, that is, they cover the post-hospitalization costs up to your base sum insured. However, there are insurers that mention a limit. For instance, United India's Family Medicare policy covers post-hospitalization expenses up to 10% of the sum insured.

👉 Claim must be accepted under inpatient benefit 

Post-hospitalization expenses will be covered only if you undergo hospitalization for a continuous period of 24 hours or more and the insurance company has approved a claim under the inpatient benefit under your health insurance plan.

👉 Should be prescribed by the treating doctor 

The insurance company will cover only those P\post-hospitalisation costs under your policy that are prescribed by the treating doctor. For instance, you undergo heart surgery, and one month after you're discharged, you get an x-ray of your heart done but it is not prescribed by the doctor who conducted the surgery. Such costs will not be covered by your policy.

👉 Available for specific benefits

While all health insurance policies cover post-hospitalization expenses that you incur after you undergo an inpatient hospitalization, there are some policies that also cover post-hospitalization expenses that are incurred for psychiatric illnesses, organ donations, and home healthcare. Some policies that allow this are - 

• Aditya Birla Active Health
• Digit Health Care Plus
• Magma One Health Policy
• National Insurance Mediclaim Plus Policy
• National insurance Parivar Mediclaim Plus Policy
• Oriental Mediclaim Insurance Policy 

Please note: The limits and conditions mentioned above may vary across insurance companies. Ensure you go through your policy documents before you opt for this benefit.

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