Claiming Medical Insurance Without the 24-Hour Hospitalization Requirement

Claiming Medical Insurance Without the 24-Hour Hospitalization Requirement

When it comes to claiming health insurance, the conventional notion has often been that a 24-hour hospitalization is an essential prerequisite for coverage. However, amid stringent guidelines, there exist certain exceptions that offer a glimmer of hope for individuals seeking insurance coverage for medical procedures that don’t necessitate an extended stay in a hospital. These exceptions are commonly referred to as day-care treatments.

The Insurance Regulatory and Development Authority of India (IRDAI) has distinctly defined hospitalization as the admission of an individual to a hospital, requiring at least 24 consecutive in-patient care hours, albeit with a few specific procedure-based exceptions.

Inpatient care primarily pertains to medical treatments that mandate an insured individual to remain in a hospital for more than 24 hours in the context of a covered event. In stark contrast, day-care treatments are explicitly defined within the confines of policy verbiage, encompassing medical treatments and surgical procedures conducted under the influence of general or local anesthesia. These procedures are typically carried out within the confines of a hospital or a day-care center, all within a span of less than 24 hours.

But what does this type of insurance claim encompass? Well, this insurance can be invoked for a variety of medical treatments administered under the influence of local or general anesthesia, all of which are typically completed within a 24-hour timeframe. Common treatments that fall under this category include tonsillectomy, chemotherapy, cataract surgery, nasal sinus aspiration, radiotherapy, hemodialysis, coronary angiography, free skin transplantation, and arthroscopic knee aspiration.

It’s crucial to acknowledge that outpatient expenses, such as doctor consultations, tests, and investigation costs, are not included in this coverage, regardless of their potential for a hospital stay of fewer than 24 hours. Outpatient treatments do not necessitate hospitalization, irrespective of the remarkable technological advancements in the field of medicine.

An important legal precedent was set on March 17 when the Vadodara consumer court declared that a medical insurance claim could be valid even if a person was hospitalized for less than 24 hours. This ruling came in response to a complaint filed by Ramesh Chandra Joshi, a Vadodara resident, against the National Insurance Company in August 2017 after the company denied his health insurance claim.

Joshi had submitted an insurance claim amounting to Rs 44,468, which the insurance company initially denied on the grounds that he did not meet the 24-hour hospitalization requirement. The consumer court not only directed the insurance provider to honor the claim but also awarded Joshi an additional sum of Rs 3,000 for mental distress and Rs 2,000 to cover his court expenses. This ruling serves as a significant precedent in recognizing the legitimacy of insurance claims related to day-care treatments.

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