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  • 24-hour hospitalisation not required for claiming insurance in these scenarios

    In health insurance, 24-hour hospitalisation is often considered as a fundamental requirement for coverage. However, as with any rule, there are exceptions. These exceptions, known as day-care treatments, are a ray of hope for individuals seeking coverage for medical procedures that don't necessitate an extended stay in the hospital.

    Girish Nayak, Chief of Technology and Health Underwriting & Claims, emphasises the pivotal role of the 24-hour hospitalisation criterion in indemnity-based health policies. According to Nayak, this criterion is in alignment with the definitions put forth by the Insurance Regulatory and Development Authority of India (IRDAI).

    IRDAI defines "hospitalisation" as the admission to a hospital for at least 24 consecutive in-patient care hours, with a few specific procedure-based exceptions. Additionally, "inpatient care" refers to treatments that require an insured individual to stay in a hospital for over 24 hours for a covered event.

    While the norm dictates that insurance claims typically entail medical treatments requiring over 24 hours of hospitalisation, there exists a flexible exception for day-care procedures. Day-care treatments, as defined by policy wordings, encompass medical treatments and surgical procedures undertaken under the influence of general or local anaesthesia in a hospital or a day-care centre in less than 24 hours.

    What's included?
    These procedures encompass a variety of medical treatments administered under local or general anaesthesia, all of which are typically completed within 24 hours. Some common day-care treatments included in health plans are cataract surgery, tonsillectomy, chemotherapy, radiotherapy, hemodialysis, coronary angiography, nasal sinus aspiration, free skin transplantation, and arthroscopic knee aspiration.

    What's not included?
    It's essential to note that out-patient expenses, such as doctor consultations, tests, and investigations, are excluded from the scope of day-care treatments, despite their potential for hospitalisation for less than 24 hours.

    Distinguishing day-care treatments from out-patient treatments is crucial. Out-patient treatments do not require hospitalisation, regardless of technological advancements in medicine. On the other hand, day-care treatments do necessitate hospitalisation, although the duration is reduced due to the benefits of medical developments.

    The bottomline
    The procedure for filing claims for day-care treatments mirrors that of regular claims. Policyholders should consult their policy prospectus for a comprehensive list of day-care treatments covered in their plan.

    All insurers offer coverage for day-care treatments, with differences lying in the specific treatments and surgeries covered by each insurer. Furthermore, these treatments often come with the convenience of cashless claim settlement.