Individual Insurance

Domiciliary hospitalisation means treatment which is taken place at home and lasts for more than three days which in the normal course would require treatment at hospital or nursing home.

The insurer would allow domiciliary treatment only if- 

  • The condition of the patient is such that he/she can’t be taken to the hospital or nursing house
  • The patient can’t be taken to a hospital due to lack of accommodation thereon

However, there are certain medical conditions or treatments which are not covered under domiciliary treatments, such as – 

  • Bronchitis
  • Arthritis, Gout or Rheumatism
  • Asthma
  • Diabetes Mellitus and Insipidus
  • Cough, cold and Influenza
  • Chronic Nephritis
  • Diarrhea, Dysentery and Gastroenteritis
  • Hypertension
  • Epilepsy
  • Tonsillitis and Upper Respiratory Tract Infection, Laryngitis or Pharyngitis
  • Pyrexia of unknown origin for a period of fewer than ten days
  • Psychiatric or Psychosomatic Disorders

Also, for domiciliary hospitalisation cover, many times health insurance companies tie up with healthcare companies in order to offer in-home services to its policyholders. In this situation, the health insurance companies settle the claim only if you avail treatment from these particular service providers.

Further, some health insurance companies cover domiciliary hospitalisation up to the sum insured, while in other, the coverage is restricted to a certain limit. In those health insurance policies where the domiciliary coverage is limited, the restriction can either be in absolute terms or shown as a certain percentage of the sum insured.

Case: 1

Raj is employed with a leading automobile company as a senior engineer. His work requires him to visit offshore location frequently. Last year, when he was in Pune, he complaint of diarrhea and fell ill with high fever. His wife, Anita took him to a nearby hospital where the doctor diagnosed it as a simple case of fever due to exertion. The doctor gave him some medicines, however, his condition worsened. His wife again took him to the doctor who now diagnosed it as a food poisoning case. The doctor asked him to get admitted to the hospital.

Raj’s employer was offering group health insurance policy to him which was covering domiciliary hospitalisation as well. It means, the expenses incurred on the treatment taken place within the house will be covered under the health insurance policy. However, certain conditions are laid down like, treatment at home should go beyond three days and treatment should be taken place at home only when it is difficult for the patient to go to the hospital and when no bed is available at a hospital or nursing home.

In this case, Raj decided to avail the benefit of domiciliary hospitalisation cover. So instead of getting hospitalised, he took treatment at home. When after 15 days, he was declared fit, Raj decided to approach his group health insurance company for the reimbursement of medical expenses which he incurred on his treatment at home.

However, in this case, the group health insurance refused to settle the claim due to the following reasons –

  • Though hospital bed was available, Raj still decided to take treatment at home
  • Fever and food poising were not covered under domiciliary hospitalisation
  • Raj’s condition was such that he could have easily gone to hospital for the treatment

Read More: What Is Domiciliary Hospitalization in Health Insurance Policies?

Case: 2

Meenal was on an official trip to Chennai when she suddenly started complaining of a headache and chest pain. Her colleague, Jyoti rushed her to a hospital where doctors confirmed it as a mild heart attack.

Unfortunately, no bed was available in the hospital, and therefore, doctors referred her to another hospital. However, instead of taking her to another hospital, Jyoti took Meenal to her home where she called her family doctor and started her treatment at home only.

As the employer of Meenal was offering a corporate health insurance with domiciliary hospitalisation cover, she approached the insurer for reimbursement of medical expenses after recuperating. However, the group health insurance company refused to settle the claim as Jyoti could have taken Meenal to another hospital. There was no need of treating her at home.

Though Meenal had a cardiac arrest, it was minor, and she could have easily been taken to another hospital.

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