Understanding home treatment coverage in health insurance plans

At the height of the Covid pandemic, there were reports of hospital beds not being available for new patients seeking hospitalization and treatment. Imagine facing such a situation or some other unforeseen circumstance where you are forced to take care of yourself at home for your health condition.

But do health insurance companies accept home care claims?

This is where the home coverage of health insurance plans comes into play. When is home treatment allowed, how is the claim settled and which pathologies and treatment methods are not provided for by the health insurance companies? Here\’s what you need to know about home care claims in health insurance.

When is home treatment allowed?

It\’s not like you can stay at home and receive all the necessary care because you find the environment comfortable and familiar. Insurance companies have specific rules about accepting such claims. At least one of the following conditions is generally required for insurance companies to accept claims.

First, a registered doctor must certify that it is better for you to be treated at home under your current circumstances than to be transferred to a hospital ward.

Of course, otherwise you should have needed inpatient treatment in a hospital.

Secondly, it must be proven that there are no suitable hospital beds available at contracted or non-contracted hospitals near the place of residence or even within the city. That is, hospitals that operate at full patient capacity may not be able to admit you, therefore making home treatment necessary.

Thirdly, a registered doctor must certify that moving you to hospital may aggravate or worsen your current health condition and that treatment at home would be a better option under the circumstances.

Insurance coverage

Policies from companies such as HDFC Ergo (health suraksha), ICICI Lombard (health advantadge), Niva Bupa (ReAssure), Star Health (comprehensive insurance) and Royal Sundaram (family plus) cover home care costs.

Often requests for home care are settled on a reimbursement basis. So, you will need to pay first and register your claim later. Usually, the costs of the treatment are covered.

But there are some nuances in the specific policies of health insurers. These include pre- and post-hospitalization costs.

Niva Bupas ReAssure does not pay them, even if it allows the cost of treatment.

However, Royal Sundaram\’s family plus policy states that if a claim is accepted under the home treatment scheme, pre and post hospitalization costs are also covered.

If the physician treating you recommends a qualified nurse to meet your needs along the journey to recovery, then ICICI Lombards health AdvantEdge allows for that expense as well.

What is excluded

Insurers do not allow home-hospitalization requests for all types of ailments. In order for a complaint to be taken into consideration, the treatment must last at least three consecutive days. For any period less than that, insurers mostly reject such claims.

Star Health also allows claims for AYUSH treatment (ayurveda, unani, siddha and homeopathy), while most insurers reject such claims.

Most insurers refuse to make claims for a variety of ailments. These include asthma, bronchitis, tonsillitis and upper respiratory tract infection including laryngitis and pharyngitis, cough and cold, and flu.

Other common events such as arthritis, gout and rheumatism, chronic nephritis and nephritic syndrome, diarrhea and all types of dysentery including gastroenteritis, diabetes mellitus and insipidus, epilepsy, hypertension and pyrexia of unknown origin.

In short, normal outpatient type treatments where you visit a doctor, take your prescribed pills, and get adequate rest to recover will not be entertained. Chronic conditions requiring extended outpatient or home care will also not be covered.

You must carefully keep all documents, medical certificates and recommendations, prescriptions and receipts relating to home treatment, so that the reimbursement process is smooth.

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