Reading through a policy document can be difficult, worse if you miss the critical part. One of them is the definition of “hospitals” used by health insurance companies. The technical implications of the plans frequently make buying health insurance, or any other type of insurance, complex. Either we take our agent’s advice, or we listen to that one colleague who seems to know more about health insurance.

Did you know? In India, the overall prevalence of health insurance was just under 35% in the 2018 fiscal year ^[1]. Regardless of the sources we use, any carelessness in understanding the technical jargon will limit how much the insurance companies will fulfil our claims.

Hospitalisation is one technical feature of health insurance plans that we frequently overlook.

What is a hospital?

A hospital offers in-patient care and daycare treatments for illnesses and injuries under any health plan. It can qualify as a hospital if they fulfil the following criteria:

1. If the institution is located in a town with a population under 10 lakh, it must have at least ten in-patient beds. If it is located in another area with a population greater than 10 lakh, it must have a minimum of 15 in-patient beds.

2. The facility should have a skilled nursing staff on duty round-the-clock in addition to medical professionals or doctors in control.

3. A completely furnished operating room should be available for surgical procedures.

4. It should keep daily patient records, and in the event of claims, the authorised personnel of the insurance company should have easy access to this information.

Make sure the hospital satisfies the requirements above, seeking reimbursement from your health insurance provider and allowing yourself to be admitted for treatment.

Know the Difference

Along with ensuring your hospital satisfies the requirements, it is better to find out if it is a part of your insurance provider’s network.

Network Hospitals: Insurance companies have partnerships with numerous hospitals across the nation. Under the Preferred Provider Network are these hospitals*. One can use the cashless health insurance facility to settle hospitalisation claims for health insurance because insurers have their separate Third-Party Administrators (TPAs) at all network hospitals.

Non-Network: You always have the option to receive care outside of the network. Keep in mind, though, that you would initially be responsible for covering the costs. The bills can eventually be sent to the insurance provider for payment and claim resolution.*

Making Hospitalization Claims

Now that you know the distinction between network and non-network hospitals, you can recognise a hospital as being accepted by the policy’s terms.

A hospital visit alone does not give you the right to file a claim. A covered person must stay longer than 24 hours in a licenced hospital. The hospitalisation benefit can also cover some procedures that don’t keep the patient in the hospital longer than a few hours.*

You may also submit a claim for pre- and post-hospitalisation costs if you are an insured person. In most cases, this coverage extends to all charges for the treatment incurred within 30 days of the hospitalisation.

Benefits for hospitalisation also provide coverage for at-home care. Therefore, medical treatment can be received at home if the insured person is not in a condition to be transported to a hospital, or if there are no available hospital beds. It is also possible to make claims for such therapies. You can check more about the benefits of health insurance.*

Given that hospitalisation benefits are a part of all health insurance plans, it is best to understand the feature before choosing the appropriate plan.*

* Standard T&C Apply

Insurance is the subject matter of solicitation. For more details on benefits, exclusions, limitations, terms, and conditions, please read the sales brochure/policy wording carefully before concluding a sale.