Day Care Treatment in Health Insurance

Daycare treatments encompass medical procedures and treatments that necessitate hospitalisation but for a duration of less than 24 hours. Thanks to advancements in medical technology, treatment processes have become significantly shorter. 

Examples of common daycare treatments include cataract surgeries, nasal sinus aspiration, cancer chemotherapy, and cancer radiotherapy, among others. Hence, it's important not to confuse OPD consultations related to sprains, fractures, and other minor procedures as daycare treatments. Health insurance plans have become essential as healthcare costs continue to rise. While most insurance providers cover extended hospital stays and major treatments or surgeries, there are many procedures that do not require prolonged hospitalisation but can still strain patients' finances.  

Fortunately, many health insurance policies now offer coverage for daycare treatment procedures requiring less than 24 hours of hospitalisation. However, it's important to note that not all insurance companies cover all types of daycare procedures. Therefore, it is advisable to thoroughly check the coverage for daycare treatments before purchasing a policy.  

What is Covered Under Health Insurance for Day Care Treatments?

Health insurance plans now provide coverage for day care treatments, which encompass the medical expenses associated with surgeries, treatments, or operations that require the policyholder to spend less than 24 hours in the hospital. Examples of day care treatments include chemotherapy, eye surgery, dialysis, and various illnesses or injuries that necessitate only a few hours of care at a day care center.

The following is the list of treatments covered under Daycare treatment: 

Additionally, surgeries performed on the digestive tract, male and female reproductive organs are also covered.

What is not Covered Under Health Insurance for Day Care Treatments?

Not all short-term medical procedures are covered under day care treatment in health insurance. Treatments administered through the Outpatient Department (OPD) are not classified as day care procedures.

For instance, medical consultations for minor injuries, common illnesses, and regular check-ups fall under the category of OPD. These procedures typically do not involve major surgeries and therefore are not covered as day care treatments.

Insurance Companies Offering Day Care Treatments:

Factors to be Considered When Choosing a Day Care Plan:

Day care procedures are covered subject to them being in the by the particular insurance company. When looking for policies that cover day care procedures, it is advisable to look for ones that cover a broad range of categories instead of ones that list specific procedures as the broad categories generally cover a lot more surgeries and procedures.

How to File a Cashless Claim for Day Care Treatments in Health Insurance

Cashless claim process for network hospitalisation: 

1. Select a network hospital where you plan to undergo the day care procedure and inform your insurance provider before your hospitalisation. 
2. The hospital will notify the insurer about the treatment, confirming that it falls within the coverage terms and conditions for day care procedures. 
3. The hospital will receive direct payments from the insurance company as per the terms of your day care procedure coverage. 

How to File a Reimbursement Claim for Day Care Treatments in Health Insurance

Reimbursement claim process for non-network hospitalisation: 

1. Choose a non-network hospital for your day care procedure and inform your insurance provider prior to the hospitalisation. 
2. Pay for all the treatment-related expenses out of your own pocket. 
3. Gather all the necessary documents and submit digital copies to your insurer to initiate a reimbursement claim. 

Eligibility Criteria for Day Care Treatments in Health Insurance

The eligibility of medical treatment for coverage as a day care procedure is based on three key factors: 

1. Medical Necessity: The procedure or treatment must be deemed medically necessary by a healthcare professional. 
2. Hospital Admission: The procedure or treatment should require the policyholder to be admitted to a hospital, even if it is for a duration of less than 24 hours. 
3. Short Duration: The procedure or treatment should be made possible due to advancements in medical technology, allowing it to be completed within a timeframe of less than 24 hours. 

Understanding Outpatient (OPD) Treatment in Health Insurance

Outpatient Department (OPD) treatment facility offers the patients doctor’s consultation regarding health issues. Under OPD, patients need not get hospitalised, rather they can visit the medical facility for other purposes, such as diagnostics purposes, consultation, pharmaceutical, et

While OPD still feels similar to daycare, the actual difference can be explained with the level of hospitalisation involved in either of these cases. For instance, in a day care treatment, a patient needs to be admitted to the hospital for however short a duration to trigger an insurance claim. On the other hand, an OPD is getting a procedure done without needing to be admitted. A perfect example for OPD would be root canal, which could be taken care of with a routine visit to a dentist's office rather than getting admitted.

 Coverage of Outpatient (OPD) Treatments in Health Insurance

The following is the list of treatments covered under Outpatient Department: 

1. Minor surgeries 
2. Dental treatments 
3. Diagnostic tests and X-rays 
4. Vaccinations and routine check-ups 
5. Doctor’s fees 

Day Care vs. Outpatient (OPD) Treatment: Key Differences in Health Insurance 

Here are the differences between Outpatient Department and Daycare treatments: 

Claim Settlement Process for Day Care Procedures in Health Insurance

Day care procedures are covered by the health insurance policy's protection, thus the policyholder can submit a claim for one using the same methods as filing a standard health insurance claim.  Making settlements for day care treatments is quite similar to what it is with regular hospitalisation. To make a claim, you would need to submit all the relevant documents regarding the treatment you have availed within the timeline specified in the fine print. There's also an advantage for you in case of day care treatments as they are usually planned well. For instance, when you getting any of the day care related procedures, you can step into one of the many network hospitals affiliated to your insurance provider. This will enable you to take the cashless route as your insurance company will handle all the payments in your stead. To make this happen, you should inform your insurance provider a few days in advance and also provide all the necessary documentation for the treatment you have availed.

Claim Settlement Process for OPD Procedures in Health Insurance

Getting an OPD treatment claim is slightly different from daycare ones as it works like indemnity-based plans. Here, you will need to pay for your treatments yourself and later opt for a reimbursement by presenting all the paperwork. An aspect worth noting here is that OPD treatments usually come with a sublimit and the cost of any breach in limit will have to be borne by you.

To sum it up, health insurance jargons aren't as hard to comprehend as they are made to be. All that is expected of a prospective policy buyer would be to do their due diligence and read through the terms and conditions of the insurance they are buying.

GST rate of 18% applicable for all financial services effective July 1, 2017.

Disclaimer: Premiums may vary depending upon factors like age, location and prevailing taxes/GST.