Domiciliary hospitalization in a health insurance plan refers to a situation where the insured is considered to be hospitalized, even when he/she is still at home. Expenses incurred on domiciliary hospitalization are covered by your health insurance policy only if the following conditions are met:

  • The treatment was for an illness, injury or disease for which hospitalization would be required in normal circumstances.
    • The condition of the insured patient does not allow him/her to be shifted to a hospital or nursing home. Or
    • The patient had to undergo the treatment at home because of the unavailability of accommodation at the hospital(s).
  • The treatment lasted at least three days.

Despite meeting all the conditions above, treatments for the following diseases (or type of treatments) will not be considered domiciliary hospitalization:

Bronchitis

Epilepsy

AsthmaCough, cold and Influenza
Diabetes Mellitus and InsipidusPyrexia of unknown origin for a period of fewer than 10 days
Chronic NephritisPsychiatric or Psychosomatic Disorders
Diarrhoea, Dysentery, and GastroenteritisArthritis, Gout, or Rheumatism
HypertensionTonsillitis and Upper Respiratory Tract Infection, Laryngitis, or Pharyngitis

 

Is it Included in Your/Employer’s Health Policy?

Domiciliary expenses are not necessarily covered in every health insurance policy, whether group health or individual health plan. Any or multiple of the following conditions may apply:

An additional premium may be payable depending on the conditions above for availing this cover. Also, additional conditions like the type of treatment availed will also apply. Insurers, generally, only cover the expenses incurred on Allopathic treatment and not for AYUSH (Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homoeopathy) treatments.

 

Read About: What Kind of Treatments Are Not Covered By Group Health Insurance Plans?

 

A case on Domiciliary Hospitalization

When the Domiciliary Expenses are Covered

Shweta Dhillon is a homemaker and suffers from occasional imbalance disorder. Although she’s undergoing the treatment at times, it is difficult for her to move unassisted. One day while climbing the stairs she lost balance, fell, breaking her leg.

She had also sustained some injury to her head and neck and fell unconscious. As there was no one at home at the time, her treatment and first aid were delayed causing blood clots and severe swelling in the broken leg.

It was decided that moving her to the hospital would be too difficult and can be hazardous for her condition. Hence the doctor decided to set up the equipment at the house itself and started treatment to normalize the condition of her leg so that a plaster can be administered.

It took about 5 days for the swelling to tone down and clots to clear, and plaster was put in place to stabilize the bone finally.

Ranjeet Dhillon, the husband of Shweta, decided to claim the expenses from his group health insurance policy. Fortunately, the policy covered domiciliary treatment though only up to 15% of the total Sum Insured.

For Ranjeet, the applicable limit for domiciliary treatment had been Rs. 75,000 and after applying co-pay on the total bill amount he received Rs. 12,000 as reimbursement from the group health insurance plan.

When the Domiciliary Expenses are Not Covered

Pranav is employed with a leading MNC as a Tech Auditor and had to frequently visit offshore locations. After one such exhausting trip, he fell ill with severe fever and diarrhoea.

Initially, the physician whom Pranav consulted, offered medication diagnosing his condition as a simple case of food poisoning. However, after his condition worsened a bit, the physician asked him to get admitted to a hospital.

 

See: What is covered under Group Health Insurance?

 

Pranav knew that domiciliary hospitalization expenses are covered under his employee health insurance plan, and decided to get the treatment at home instead.

He got well after about 10 days since his return and decided to claim reimbursement for his treatment. His claim was rejected. The insurer gave the following two reasons for rejection:

  1. Pranav’s was in good enough condition to get to the nearest hospital
  2. Domiciliary treatments of Diarrhea and fever are not covered under the domiciliary expenses cover.