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Know the fine print before you buy health insurance


Minimum 24 Hours inpatient Hospitalisation Clause

A Health Insurance policy stipulates that a Claim is valid only if the Insured has been hospitalized for at least 24 hours.

However, there are certain surgeries that don't require 24 hours of hospitalization, thanks to advances in science and technology.

This is where a compulsory 24 hours hospitalization clause needed relaxation to include such expenses.

Because this was causing moral hazard as insured and the hospital with mutual understanding extended hospitalization to 24 hours to get coverage. Either in real time or just in papers.

Insurers have listed around many such treatments called “Day care procedures where and allow the medical coverage even if 24 hours minimum hospitalization is not given. Sample list is given here.

Even if it is not listed in the policy document, you can request them to include it and take approval before going for admission.

Don’t get confused between day care procedures and outpatient expenses.

No insurance company pays for the stand alone Outpatient treatments like POP because of bone fracture, stitches with local anesthesia, doctor consultations, health tests etc.,

There are more than 580 Day Care procedures. The number of such Day Care procedures being covered differs from insurer to insurer.

Only 24 hours inpatient hospital admission is not enough. There should be an inline treatment as well.

Let's say I experience chest pain at night and I go to emergency hospitalization thinking it may be a heart attack.

After being admitted and undergoing tests, the doctor determined that my chest pain was due to a gastric problem and that no treatment was required.

I will be happy that nothing has happened to me, but I will be disappointed that my claim for admission and health tests have been rejected because there is no inline treatment.

But in case the doctor finds some issue with my health and gives me some treatment with minimum 24 hours inpatient hospitalisation, then the hospitalization bill along with those health tests and medicines gets covered.

In certain cases when the patient’s condition is not such that he can be moved to Hospital, insurers agree to consider the claim and reimburse the expenses under the Domiciliary hospitalization cover. However you need to check if your policy has such cover.

Reasonable and customary charges is one of the most dreadful clauses in Health Insurance.

The terms reasonable, usual and customary refer to the average claim paid by your Insurance Company for a particular ailment.

A charge is considered reasonable, usual and customary if it matches the general prevailing cost of that service within your geographic area, which is calculated by your insurance company.

The insurance company then uses this information to determine how much it’s willing to pay for a given service in your area.

This means that if your hospital charges above the reasonable and customary charge, you may have to pay the remainder.

This clause gives a lot of room for an insurance company to cut down the claim amount and in fact it is the most disputable clause in the whole policy document.