Group Health Insurance

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Cover for pre-and post-hospitalization expenses

Before a hospitalization, you might have to undergo a series of tests, and post-hospitalization care might also entail some expenses. If your employer offers group health insurance, the insurer might cover some or most of these expenses. This post attempts to offer some clarity on the expenses that may or may not be covered under a group mediclaim policy.

Pre-and post-hospitalization expenses

You may incur expenses before you move to a hospital for in-patient treatment. A group health insurance policy typically identifies the following as pre-hospitalization expenses: medical tests, medicines, vaccinations, and doctor’s/medical practitioner’s fees.

Recuperation or post-hospitalization expenses refer to the medical expenses incurred by the insured to regain their pre-illness/injury state of health.

Insurance cover

Insurers cover both pre-and post-hospitalization expenses if the following conditions are met:

  • The insurer accepts the claim for hospitalization expenses
  • The expenses arising from the same illness/injury/disease which necessitated hospitalization
  • The expenses occurred within prescribed time limits:
    • For pre-hospitalization: 30 to 60 days before hospitalization
    • For post-hospitalization: 60 to 90 days after hospitalization
  • Hospitalization was in-patient and not domiciliary.

Read More: What benefits are available under Employee Group Health Insurance?

Case study: Cover for pre-and post-hospitalization expenses

Karan Dumra had an intermittent fever over three days. He thought it was a simple viral fever that could be suppressed with generic anti-viral medication. On the fourth day, he experienced shivering and a very high fever. So, he decided to consult a doctor. Since Karan was too ill to travel, the doctor came home. After preliminary checks, the doctor advised blood tests and an ultrasound to check his liver.

See: What Is Covered Under Group Health Insurance?

It took two days for the test reports to come in. Meanwhile, Karan’s situation worsened. He vomited a couple of times, and his worried family decided to admit him to a hospital for treatment.

They had already spent about Rs 12,000 on medical tests and doctor’s fees. Karan spent three days in the hospital. The hospital was one his insurance provider had listed as a network hospital. So, the insurer directly paid all the in-patient treatment bills.

Karan was discharged but he had not fully recovered. He spent another five days on medication at home. The doctor asked for more medical tests to ensure that Karan had improved and to determine when to stop the medication. Two more physician’s visits occurred in this period. While recuperating, Karan spent another Rs 15,000.

Karan’s group health insurer covered pre-and post-hospitalization expenses for up to 30 days before and 60 days after hospitalization. Thus, Karan was able to file a claim for these expenses with the insurer. Since the insurer did not apply a co-pay clause, it reimbursed 100% of the cost of medicines, medical tests, and physician’s fees.

Case study: No cover for unrelated expenses

Ranjeet had been under medication for hypertension for 20 days when he met with an accident. Owing to his condition, Ranjeet’s subsequent hospital bill and tenure of treatment both exceeded the normal average for accident victims.

After his discharge from the hospital, Ranjeet was housebound for another 30 days. The hypertension medication continued during this period. His company’s family floater health policy took care of all the expenses incurred on in-patient treatment, except hypertension medication. Later, Ranjeet filed a claim for pre-and post-hospitalization expenses and included the costs of the hypertension medicine as well.

The insurer rejected his claim for pre-hospitalization expenses as it was not related to the cause of hospitalization. It also deducted the amount spent on hypertension medicines from the post-hospitalization claim (again because it was not related to the cause of hospitalization and because the insurer never covered hypertension medicines even during in-patient treatment).

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