Group Health Insurance

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Often hospitalization is required after a series of tests and treatments have already been performed without improvement in the patient’s condition. Also, similar expenses will be incurred after the patient has been discharged from the hospital. Most individual and group health insurance plans have provisions to cover such expenses.

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Pre-hospitalization expenses refer to the expenses incurred before a patient is moved to a hospital for inpatient treatment. Following expenses can be considered as part of the pre-hospitalization expense in a health insurance policy:

  • Medical Tests
  • Medicines
  • Vaccinations
  • Doctors’/Medical practitioner’s fees

Post-hospitalization expenses are similar in nature, and sometimes referred to as ‘recuperation expenses’. Meaning the medical expenses incurred by the insured to regain his/her pre-illness/injury condition.

Both pre and post-hospitalization expenses will be covered, only if the following conditions are met:

  • The insurer has accepted the claim for hospitalization expenses
  • The expenses have been incurred for the same illness/injury/disease for which the hospitalization was required.
  • The expenses have been incurred within the time limits prescribed by the insurer:
    • Pre-hospitalization time limit ranges between 30 to 60 days before hospitalization
    • Post-hospitalization time limit ranges between 60 to 90 days after hospitalization
  • The Hospitalization was inpatient treatment and not domiciliary hospitalization

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

Case on Pre and Post Hospitalization Expenses

When They are Covered

Karan Dumra had been feeling ill for a while before he had to request sick leave. He had been suffering for three days with intermittent fever, which he thought was a simple viral and could be suppressed with generic antibiotics.

On the fourth day, he experienced shivering and very high fever, which was simply not normal viral case anyone in his family had seen before. So, they decided to go to a doctor for consultation. Since it was quite difficult for Karan to move out, the doctor was called home, and after preliminary checks, he advised blood tests and ultrasound for liver, etc.

See: What Is Covered Under Group Health Insurance?

It took about two more days before the reports could be collected and meanwhile, Karan’s situation worsened. He was unable to digest much of the food he had and vomited a couple of times, and finally, his family decided to get him admitted to a hospital for treatment.

They had already spent about Rs. 12,000 on medical tests and doctor’s fees.

The hospital physicians started treatment after going through the test reports Karan, and his family already had done some more tests. Karan spent a total of three days in the hospital and recuperated enough to be discharged.

Hospital has been one of the network hospitals for the group health insurer of Karan’s employer, so the insurer directly paid all inpatient treatment bills.

Although Karan had been discharged, but had not recuperated from the illness fully, and ended up spending another five days on medication at home. Another set of medical tests were needed to ensure that his condition has improved and to determine when to stop the medication. Two more physician visits occurred in this period.

In the recuperation period, Karan spent a total of another Rs. 15,000.

Group health insurance cover offered by the employer covers the pre and post hospitalization expenses up to 30 days before and 60 days after the hospitalization. Since Karan’s pre and post hospitalization expenses are well within this time limit, he can file a claim for these with the insurer.

The insurer does not apply co-pay clause, therefore 100% of medicine, medical tests and physician fees had been reimbursed by the insurer in this case.

When They are Not Covered

Ranjeet has been under medication for hypertension for last 20 days when he met with an accident and had to be hospitalized. His hospital bill and tenure of treatment both were above the normal average of two weeks (15 days) for accident victims due to his condition.

Even after discharge from the hospital, he was housebound for another 30 days. Again, the hypertension medication also continued in this period. His family floater health policy took care of all expenses incurred for inpatient treatment except the medication for hypertension.

Later he filed the claim for both pre and post hospitalization expenses and included the hypertension medicine costs as well in the claim.

The insurer rejected his claim for pre hospitalization expenses as it was not related to the cause of hospitalization at all, and reduced post hospitalization claim by the amount spent on hypertension medicines (again because it was not related to the hospitalization expense, also the insurer never covered hypertension medicines even during inpatient treatment).

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