Workmen Compensation

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How to Determine Post Hospitalization Medical Expenses in a Worker Compensation Insurance?

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 should have suffered bodily injury or an accident during the policy period. A workmen compensation policy covers both the pre-hospitalization charges and the post hospitalization charges of the insured.

Usually major part of the treatment of an injured worker or an ill employee is completed during the hospitalization period.

However, some part 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 compensation insurance policy include the charges that a worker or an employee incurs for regaining wellness after hospitalization but related to the illness that was treated.

Post Hospitalization Charges

Major determinants of the post hospitalization charges in worker compensation insurance are

  • Cause for the post hospitalization expense
  • Period for which expensesare incurred after hospitalization of the person

Majority of the post hospitalization expenses incurred in a worker compensation insurance policy are:

  • Medicines prescribed by the consulting doctor
  • Follow-up-visits to the consulting doctor or physician
  • Regular test 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 is paid.New ailments during the post-hospitalisation period will not be paid for.

Additional Read: What Are the Different Type 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 given by the physician for investigations and medication purpose
  • Bills for all the relevant medical prescriptions, and,
  • Bills for any relevant tests or investigation 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 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 benefit from his workmen 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 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 had cost Rs 5000.

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 took place in his working premises, he would not have got that benefit from the insurance company.

Know all about the post hospitalization chargescovered under the workmen compensation policy before you decide to buy it.

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