Group Health Insurance

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Sometimes, we might need serious medical care but might not be able to leave home. In such circumstances, hospital-like treatment would have to be administered at home. This is domiciliary hospitalization and health insurance.

How do health insurance providers treat domiciliary hospitalization? This post attempts to offer some clarity on the issue.

Inclusions and exclusions   

Domiciliary hospitalization refers to a situation where the insurance provider considers the insured hospitalized, even when still at home. Insurance providers cover expenses incurred on domiciliary hospitalization under the following conditions:

  • The treatment was for an illness, injury, or disease that would require hospitalization in normal circumstances but
    • the insured could not be shifted to a hospital or nursing home due to their condition OR
    • hospital beds were unavailable.
  • The treatment lasted at least three days.

Despite meeting these conditions, insurers do not consider some diseases eligible for domiciliary hospitalization: bronchitis; epilepsy; asthma; diabetes mellitus and insipidus; chronic nephritis; diarrhea, dysentery, and gastroenteritis; hypertension; cough, cold, and influenza; pyrexia of unknown origin for less than 10 days; psychiatric or psychosomatic disorders; arthritis, gout, or rheumatism; and tonsillitis and upper respiratory tract infection, laryngitis, or pharyngitis. This is not a complete list but is indicative of the kind of exclusions. It is as yet unclear whether insurers will consider home treatment of Covid, if hospital beds are unavailable, as domiciliary hospitalization.

Read more: Which Factors Affect the Premium of a Group Health Policy?

Group health insurance and domiciliary hospitalization

Not every health policy, whether individual or group, covers domiciliary expenses. So, you might have to pay an additional premium to avail of domiciliary hospitalization. Insurers might also put in place additional conditions like the type of treatment. Generally, insurance providers only cover domiciliary expenses incurred on allopathic treatment and not AYUSH treatments.

Case study: when domiciliary hospitalization is covered

Shweta Dhillon is a homemaker and suffers from occasional imbalance disorder. Although she’s undergoing treatment for this condition, it is sometimes difficult for her to move around unassisted. One day, while climbing the stairs at home, she lost her balance and fell, breaking her leg. She also injured her head and neck and lost consciousness. As she was alone at home at the time, by the time help arrived, she developed blood clots and severe swelling in the broken leg.

The doctor felt that moving her to a hospital could be difficult and hazardous. So, they set up equipment at the house itself. They started treatment to reduce the swelling and blood clots on her leg so that they could apply a plaster. It was five days before the doctor could plaster her leg to stabilize the bone.

Ranjeet, Shweta’s husband, decided to claim the expenses from his employer’s mediclaim policy. Fortunately, the policy covered domiciliary treatment, though only up to 15% of the total sum insured. Since Ranjeet’s sum insured was Rs 75,000, the insurer paid him Rs 11,250 as reimbursement from the group health insurance plan. The insurer paid this amount against actual bills for putting the plaster, doctor visits, and nursing support.

Case study: when domiciliary expenses are not covered

Pranav works with a leading MNC as a tech auditor and has to frequently visit offshore locations. After one such trip, he fell ill with severe fever and diarrhea.

Initially, the physician Pranav consulted offered medication, diagnosing his condition as a simple case of food poisoning. However, after his condition worsened, the physician advised hospitalization.

See: What are the additional benefits of Group Health Insurance?

Pranav knew that his employer’s medical insurance plan covered domiciliary hospitalization expenses. So, he decided to get the treatment at home instead. In 10 days, Pranav’s condition improved. He decided to claim reimbursement for his treatment.

However, the insurer rejected his claim, pointing out that Pranav’s condition did not make it impossible for him to get to the nearest hospital. Also, they noted that the domiciliary expenses covered did not extend to treatments for diarrhea and fever.