What is Day Care Treatment in Health Insurance?

The way we receive medical care has improved over the years. Most treatments are now quicker with faster recovery and limited hospital stays. With this convenient shift, health insurance coverage has also evolved. Different types of procedures, including day care treatments, are covered in health insurance based on the type of policy. Learning about these treatments helps you better understand your coverage.

Day care treatment in health insurance refers to medical procedures that require hospitalisation for less than 24 hours due to advanced medical technology. These treatments are covered under most health insurance policies, provided they are listed in the insurer’s approved procedures. 

• Day care treatments in health insurance cover procedures completed within 24 hours but still require hospital admission and supervision.
• Day care treatments generally include eye-related procedures, cancer treatments, kidney-related procedures, treatment for ear ailments, and general surgery-related procedures.
• Day care treatments differ from OPD treatments, which do not involve hospitalisation and are typically available as an add-on.
• You can claim for day care treatment coverage through a cashless or reimbursement procedure with documents verifying your treatment details. 

Day care treatment is a middle ground between out-patient (OPD) treatments and long hospitalisations. 

The exact list of day care treatments covered in health insurance varies from one insurer to another. Some of the commonly covered categories include: 

• Eye-related procedures 
• Kidney-related procedures
• Procedures for nasal-related ailments
• Chemotherapy.  

IRDAI guidelines require insurance providers to clearly define all inclusions in policy wording. It’s best to refer to the policy terms for coverage when you buy health insurance online.

Both day care treatment and procedures performed in the outpatient department (OPD) involve short hospitalisation. However, they work differently and are covered in a different capacity in health insurance. Here’s a side-by-side comparison for clarity: 

Since day care treatments are usually included in the base cover, the claim process is pretty straightforward. A little preparation goes a long way in ensuring your claim is settled without hassle. You can either opt for a cashless or a reimbursement claim process. 

Cashless Claim Process  

You can make a cashless claim when you undergo treatment at a network hospital tied up with your insurer. Once your treatment plan is approved under the coverage, the insurer settles the eligible expenses directly with the hospital. This makes the process smoother and less taxing. 

1. Complete pre-authorisation: Inform your insurer or Third-Party Administrator (TPA) in advance of planned hospitalisation. Submit relevant documents about your treatment. You can skip this step during emergencies.
2. Get admitted: Choose a hospital within your insurance company’s network. You can check the list on the insurer’s portal or mobile app under the ‘Network Hospital’ section.
3. Submit documents to the hospital: Provide your health insurance card, ID proof, medical reports and doctor’s prescription (if any) at the hospital.
4. Seek treatment: Undergo the treatment as advised by your doctor without having to worry about the cost, as they are directly settled by your insurer.
5. Monitor additional expenses: Look out for any non-covered items during discharge. These will be out-of-pocket expenses. 

Reimbursement Claim Process  

A reimbursement claim applies when you choose a non-network hospital. You pay the hospital bills upfront and later submit all the required documents to the insurer. After verification, the insurer reimburses the eligible amount based on the policy terms. 

1. Notify your insurer: If you plan hospitalisation, inform the insurer in advance, preferably within 24-48 hours, to alert them of the potential claim.
2. Fill in the claim form: After getting the treatment and settling all hospital bills, you can fill in a reimbursement claim form. Ensure all details, such as your name, hospital, and treatment information, are accurate.
3. Submit documents: Furnish medical bills, prescriptions, reports, and discharge summaries collected at the time of discharge. You can upload them online or submit them at the nearest branch.
4. Wait for assessment: The insurer will review your claim against the day care treatments covered in health insurance, the available sum insured, and other policy terms.  

5. Receive reimbursement: Once approved, you shall receive the eligible amount in your registered bank account. The claim may be processed in a few days, depending on the accuracy of your documents and whether the treatment meets the coverage terms. 

    

The importance of having the right documents to file a claim cannot be understated. Insurers typically look for: 

• Hospital bills and payment receipts
• Doctor’s prescription
• Diagnostic reports
• Discharge summary
• Duly filled claim form
• Valid ID proof
• Health insurance policy copy
• Bank account details (for reimbursement)
• Pre-authorisation approval for planned hospitalisation while filing a cashless claim. 

Insurers may have specific requirements for additional documents based on their policy. You can check for the same in your policy document or speak to your insurer or TPA.   

As healthcare continues to evolve, it’s worth checking how medical insurance coverage differs for advanced procedures. Now that you know what day care treatment in health insurance is and how it is covered, you can take the right steps upon hospitalisation. Ensure you review your policy to verify the covered treatments to avoid surprises later.  

With insurers like SBI General Insurance offering comprehensive health insurance coverage, you can move forward with greater confidence for a range of medically essential treatments. 

1. Does day care treatment require pre-approval from the insurer? 

If you’re seeking day care treatment as a planned procedure, you will need pre-approval from the insurer. This is especially true for cashless claims.  

2. Are day care procedures covered in all hospitals or only in network hospitals? 

Day care procedures are covered in all hospitals. Network hospitals enable cashless claims, while admission in non-network hospitals qualifies for reimbursements. 

3. Is there a limit on the claim amount for day care treatments? 

Yes, claims are subject to the sum insured, sub-limits (if applicable), and the policy terms. 

4. Can multiple day care procedures be claimed in a single policy year? 

Yes, you can make multiple claims if the total amount stays within the available sum insured. 

5. Are diagnostic tests included under day care treatment coverage? 

No, diagnostic tests alone do not qualify for day care treatment coverage. They must be a part of a procedure fitting the definition of day care treatment. 

6. Does day care treatment coverage differ in family floater plans? 

The day care treatment coverage remains largely similar, but the sum insured is shared among all insured members. 

7. What happens if a procedure is not listed under day care treatments? 

If it’s not included under the day care treatments covered in health insurance, raising a claim is not possible.