What are Pre and Post hospitalization expenses covers?

By Chaitanya in Health Insurance -Claims corner

Jul 22

Pre-Hospitalisation Expenses:

    The term pre-hospitalisation expenses were defined under Chapter 1 clause 34of Guidelines on Standardization in Health Insurance Circular Ref: IRDA/HLT/REG/CIR/146/07/2016 dated 29.07.2016 as
    Pre-hospitalization Medical Expenses means medical expenses incurred during a predefined number of days preceding the hospitalization of the Insured Person, provided that:
    i. Such Medical Expenses are incurred for the same condition for which the Insured Person’s Hospitalization was required, and
    ii. The In-patient Hospitalization claim for such Hospitalization is admissible by the Insurance Company
    Other Points:
    1. In most cases, charges incurred by an individual 30days prior to his or her admission to any hospital fall within the pre-ambit of health insurance provider.
    2. Several tests such as blood test, urine test, and X-ray among others are categorized as pre-hospitalization expenses.
    3. The insurance company will pay for only those expenditures that directly pertain to the ailment/ disease for which the person was hospitalized.
    4. Any routine medication which is not directly related to the ailment/disease of the patient is excluded from the purview of Pre-hospitalisation benefit.
    5. The policyholder can claim the admissible expenses from the insurer by submitting the original bills& receipts with the copies of the doctor’s certificate and discharge summary.
    6. The important point to note here that the Pre-Hospitalisation expenses are covered and paid off only when the
    • The ailment is covered under the policy
    • And the expenses are related to such an ailment.
    7. The policyholder should be very cautious and keen and keep a record of his pre-hospitalisation expenses record so that if the costs incurred for those expenses are related to his hospitalization, the policyholder can claim from the company.
    8. If the pre-hospitalisation expenses are unrelated or routine checkups, then they are not admitted for the claim under the policy.
    9. These principles even apply to the group health insurance policies.
    10. There will be a specific time limit mentioned under each policy to claim these expenses.

    Post Hospitalisation Expenses:
    The term Post hospitalization expenses were defined under Chapter 1 clause 35of Guidelines on Standardization in Health Insurance Circular Ref: IRDA/HLT/REG/CIR/146/07/2016 dated 29.07.2016 as
    Post-hospitalization Medical Expenses means medical expenses incurred during a predefined number of days immediately after the insured person is discharged from the hospital provided that:
    i. Such Medical Expenses are for the same condition for which the insured person’s hospitalization was required, and
    ii. The inpatient hospitalization claim for such hospitalization is admissible by the insurance company.
    Other Points:
    1. These are the expenses incurred by the patient after admitted into the hospital.
    2. The number of days provided for coverage depends upon the health insurance provider. So the customer can choose the policies of his choice covering a distinct number of days.
    3. Expenses, like consulting fees for follow-up visits and discharge medicine charges, are covered under this.
    4. Generally, the policyholder should prefer a high period because his coverage is maximum to the extent of full and final coverage for his ailment.
    5. Generally, insurers offer 60 days of post-hospitalization expenses for coverage and also vary according to different policies offered by various insurers.
    6. The post hospitalization expenses can be claimed by submitting the original bills and doctor prescriptions, pharmacy bills with the insurer.
    7. If any diagnostic charges incurred by a patient as prescribed by the doctor, post-hospitalization are incurred can be claimed by the policyholder.
    8. Post-hospitalization expenses like alternative therapies are specifically excluded from the post-hospitalization expenses admissible under the claim.
    9. There will be a specific time limit mentioned under each policy to claim these expenses.

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