A worker’s compensation policy applies to accident-related bodily injury or illness due to work. To avail of the benefit of this type of policy, it is important that the worker has suffered bodily injury or an accident during the policy period. A workmen’s compensation policy covers both the pre-hospitalization charges and the post-hospitalization charges of the insured.
Usually, a major part of the treatment of an injured worker or an ill employee is completed during the hospitalization period.
Key Takeaways
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The Recovery Bridge: Post-hospitalization coverage is designed to cover the “wellness journey.” It ensures that the costs of monitoring a patient’s progress after discharge do not fall on the employer or the worker.
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The 90-Day Window: Most insurers provide a strict timeframe—usually 60 to 90 days—during which post-hospitalization bills can be submitted. Missing this deadline can lead to claim rejection.
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Strict Relatedness: Every rupee claimed after hospitalization must be linked to the original injury. For example, if Ashish was treated for a back injury, the insurer will not pay for medication for a sudden cold or unrelated fever during the recovery period.
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Evidence-Based Claims: Claims are only settled upon the submission of a Discharge Summary and a clear trail of prescriptions. The insurer must see that a doctor explicitly ordered the follow-up tests or medicines.
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Exclusion of Alternative Care: Standard WC policies strictly follow allopathic medical guidelines. Expenses for Acupuncture, Homeopathy, or Naturopathy are generally not covered, even if they help the patient feel better.
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High-Value Diagnostics: Specialized tests like MRIs or CT scans (which can cost ₹5,000 or more) are fully reimbursable if they are part of the investigation into the original work-related injury.
However, some parts of the treatment can extend beyond the period of hospitalization. Some medical expenses are incurred even after the patient is discharged from the hospital. The post-hospitalization charges in a workmen’s compensation insurance policy include the charges that a worker or an employee incurs for regaining wellness after hospitalization but are related to the illness that was treated.
Determination of Post Hospitalization Charges in worker’s compensation
Major determinants of the post-hospitalization charges in worker compensation insurance are
- Cause for the post-hospitalization expense
- Period for which expenses are incurred after hospitalization of the person
The majority of the post-hospitalization expenses incurred in a WC insurance policy are:
- Medicines prescribed by the consulting doctor
- Follow-up-visits to the consulting doctor or physician
- Regular tests are conducted for monitoring the progress or the recovery of the patient
While determining the validity of the post-hospitalization expenses, it is essential to determine whether the expense is payable according to the policy-defined period. To recover the post-hospitalization expenses the time limit is 60 to 90 days after hospitalization.
Insurance providers do not cover expenses for therapies like acupuncture and naturopathy under post-hospitalization expenses. Insurers will only cover diagnostic charges, consulting fees and medicine costs. Furthermore, expenses related to the illness that was treated for are paid. New ailments during the post-hospitalisation period will not be paid for.
Additional Read: What Are the Different Types of Medical Expenses Covered Under A Workmen Compensation Policy?
The workmen compensation insurance company requires the following documents to cover the post-hospitalization expenses incurred by the insured:
- Copy of the discharge summary with respect to hospitalization
- Any prescriptions are given by the physician for investigations and medication purposes
- Bills for all the relevant medical prescriptions, and,
- Bills for any relevant tests or investigations conducted
Case Study:
Ashish, a 34 year, individual worked in a service company. His job required him to work in shifts. During one of his general shifts, he slipped on a wet floor and injured his back severely. Upon hospitalization, his treatment began immediately. His reports showed that he had damaged his lumbar vertebrae. He was in the hospital for 15 days. The hospital discharged him upon recovery. However, his physician prescribed him various medicines and tests.
Ashish had to conduct routine check-ups to investigate his recovery. He also had to take out an MRI of his spinal cord to assess the recovery of the injury.
Ashish contacted his employer to get benefits from his workmen’s compensation policy. The insurers surveyed the matter and found that:
- Ashish was a permanent employee of the service company.
- He had slipped on the wet floor during his service hours
- Ashish informed the insurance company within the period of 60 days
- Submission of bills for his medical prescriptions as well as his x-ray examinations
- He gave a discharge summary with respect to his hospitalization
- Ashish provided the bills for his follow-up-checks with the consulting physician
Ashish adhered to all the requirements to get his post-hospitalization coverage and thus insurers settled the claim. MRIs can be expensive and this one cost Rs 5000.
Summary Table: Post-Hospitalization Coverage Dynamics
| Feature | Included Coverage | Specific Exclusions |
| Medical Scope | Prescribed medicines and follow-up doctor consultations. | Alternative therapies (Acupuncture, Naturopathy, etc.). |
| Diagnostics | Routine tests, X-rays, and MRIs (e.g., Ashish’s ₹5,000 MRI). | Investigations for new ailments unrelated to the original injury. |
| Time Limit | Usually 60 to 90 days after discharge. | Expenses incurred after the policy-defined recovery window. |
| Validity Rule | Must be directly related to the illness/injury treated in-hospital. | General wellness supplements or non-prescribed medications. |
| Claim Trigger | Slip-and-fall or injuries during “service hours.” | Injuries occurring outside of working hours or premises. |
| Documentation | Discharge summary, original bills, and doctor prescriptions. | Estimates or pro-forma invoices without final billing. |
Additional Read: When to File Claim Application under Workmen Compensation Insurance?
If Ashish had also claimed insurance for any other medical charges which did not deal with his back injury that took place on his working premises, he would not have got that benefit from the insurance company.
Know all the post-hospitalization charges covered under the workmen’s compensation policy before you decide to buy it.
Frequently Asked Questions (FAQs)
1. What exactly does “Post-Hospitalization” cover in a WC policy?
A) It covers medical expenses incurred after you are discharged from the hospital, provided they are directly related to the injury you were hospitalized for. This includes follow-up visits to your surgeon, diagnostic tests (like blood work or X-rays), and the specific medicines mentioned in your discharge summary.
2. How long after leaving the hospital can I continue to claim expenses?
A) Most policies have a defined period, typically between 60 and 90 days from the date of discharge. Any medical costs incurred after this window expires are usually the responsibility of the employee or the employer.
3. If I catch a viral fever while recovering from a workplace back injury, is the fever treatment covered?
A) No. Post-hospitalization benefits only apply to the specific ailment that was treated during the hospital stay. New or unrelated illnesses that occur during the recovery period are not eligible for a claim under the Workmen’s Compensation policy.
4. Why was Ashish’s ₹5,000 MRI covered by the insurance company?
A) Ashish’s MRI was covered because it was a routine check-up prescribed by his physician to investigate the recovery of his lumbar vertebrae, which was the original injury sustained during his shift. Since it was directly related and within the time limit, the insurer settled the cost.
5. Are “wellness therapies” like massage or acupuncture covered if they help my recovery?
A) No. Insurance providers generally exclude alternative therapies like acupuncture, naturopathy, or herbal treatments. Coverage is strictly limited to diagnostic charges, consulting fees, and conventional medicine costs prescribed by a licensed MD or specialist.
About The Author
Rahul Kumar
MBA Finance
With a wealth of experience in the insurance industry, Rahul is a seasoned writer specializing in articles related to workmen compensation policies (WC policies) for SecureNow. With 12 years of experience in the field, he has acquired in-depth knowledge and expertise in workmen compensation insurance, understanding its complexities and nuances. Their insightful articles provide valuable insights into the importance of WC policies for businesses and employees alike, offering practical advice and guidance on navigating the intricacies of insurance coverage. Trust him to deliver informative and engaging content, backed by years of experience and a passion for educating readers about insurance-related topics.
