As the second wave hit the second-most populous country in the world, the rising cases exposed the health care system and the country's preparation for the pandemic. Home care treatment came into the spotlight during pandemic as some patients underwent such treatments. Homecare treatments or domiciliary hospitalisation are suggested if a policyholder is in such circumstances that the treatment can be conducted at home or if a hospital room is not available. In such scenarios, the insurer shall reimburse the medical expenses as per the policy terms and conditions.
Although the insurance company endeavors to fulfil the claims raised, certain instances might result in a denial of claim settlement or settlement with a few deductions. One should understand as to why your health insurance claim may face a deduction or a denial. Since one can’t avoid all probable causes, it is imperative to know what steps to take if your claim gets rejected:
Things to know before claiming homecare treatment:
Opt for home care treatment while purchasing the policy
Not every insurer provides home care treatment coverage. So, before purchasing the policy understand if home care treatment is covered under your policy plan. This is not a default coverage provided by the insurer. If you opt in to take benefits of home care treatment then the insurer may request you to pay extra premium cost as per the coverage opted.
Coverage and criteria for different types of treatment
There are different types of treatments for which homecare treatment may not be covered by your insurer. Homecare treatments for asthma, bronchitis, hypertension, gout, arthritis, pharyngitis, chronic nephritis, epilepsy and few more may not be covered by your insurer. Certain insurers will cover only specific expenses incurred under allopathy treatment. Homeopathy or ayurvedic treatment availed at home may not be covered under your policy plan. Also Insurers could allow Home treatment in a network only. Before making a claim or before undertaking a home care treatment, understand the policy exception and eligibility to avoid disappointment during claim.
Inform the insurer at the earliest
Inform your insurance provider about why are you undergoing home care treatment and why you can’t undergo treatment in the hospital. The insurer needs to find your reason for home care treatment satisfactory. The insurer can deny your claim if you were in a condition to reach hospital but chose not to undergo hospitalization.
Avail a written communication approval from the insurer for hospitalization at home. Be mindful of saving all the required prescriptions, diagnostic reports, and detailed invoices to be well documented before making the claim.
Be cautious while upgrading and porting your policy
If you foresee a need of home care treatment then you may want to upgrade your existing policy or port it to a new insurer who provides homecare treatment coverage. Make sure to read all the policy coverage features regarding domiciliary treatments.
Know the waiting period
One has to wait for a certain time period to avail domiciliary hospitalization and the illnesses for which this benefit is being availed. If the policyholder has not fulfilled the waiting period criteria then his/ her claims would be denied.
Sum insured limit
The expenses covered under homecare treatment are restricted up to the sum insured limit.
Cap of minimum treatment day
Some insurers require a policyholder to undergo a minimum of a certain number of days of treatment to make the claim. Anything less than that may not be covered. The policyholder should get clarity with the insurer while planning home treatment.
Limit of domiciliary reimbursement
Many insurers have a set limit for domiciliary reimbursement to a certain percentage of the sum insured or others may give it as an add-on..
Minor treatment and home ICU cost
The cost incurred for minor treatment may not be covered but in case of covid treatment cost and setting up of ICU at home, oxygen cost, these costs would be covered without limit up to the sum insured as per policy terms. In certain conditions, the cost of cylinders might not be considered.
The author, Anuradha Sriram, is Chief Actuarial Officer at Aditya Birla Health Insurance. The views expressed are personal