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How does Domiciliary Hospitalization work in Health Insurance Policies?

Health insurance is a serious matter that covers up against any medical emergencies. However, there are some special cases where the benefits of a health insurance can be extended beyond a stay in hospital.

The term ‘Domiciliary Hospitalization’ means that the expenses of the policyholder will be covered even when he/she is undergoing treatment for any disease or injury at home in India. However, the following conditions need to be met in order to settle the claim -

The patient is suffering from a disease where doctor has prescribed hospitalisation for him/her and he/she has a valid ongoing base health policy.

  1. The patient cannot be shifted to any nearby hospital because that may pose a risk towards the current state of a patient. For example, a person who has a fractured leg or injury in the hips may find it difficult until initial recovery period is over to avoid further dislocation. The patient didn’t find accomodation in a nearby hospital that have enough facilities for the proper treatment.

  2. The domiciliary hospitalization cover shall be available to treatments taken only under the Allopathic Mode of Treatment.

Conditions under which domiciliary hospitalisation is not covered

Expenses incurred for pre and post hospital treatment.

  1. Any treatment that lasts for less than 72 hours.

  2. The following diseases cannot be considered for domiciliary hospitalization even they meet all the conditions stated above.

Asthma

Hypertension

Bronchitis

Arthritis, Gout and Rheumatism

Chronic Nephritis and Nephrotic Syndrome

Pyrexia of unknown origin for less than 10 days

Influenza, Cough and cold

All Psychiatric or Psychosomatic Disorders

All type of Dysenteries including Gatro-enterities

Tonsillitis and Upper Respiratory 

Tract Infection including Laryngitis and
Pharyngitis

Diabetes Mellitus Inspidus

Epilepsy


Policies where domiciliary hospitalization is not covered -

In such cases, you can avail the benefits if you add an additional rider with separate sum assured. Otherwise, you can avail it as an option where a certain amount of sum assured which is generally less than or about 15% of the sum assured.

Example of domiciliary hospitalisation cases

Let’s consider two separate cases to understand how domiciliary hospitalization will work.

Case-I

Priya Rawat is an IT professional and she usually spends his weekends by cleaning the house or cooking a nice dish for her husband. She has to balance her household chores with professional responsibility. Prolonged strain on health has made her weak and one day she fell down after losing her balance while cleaning the house. As no one was present at home at that time, she regained her senses after 3 hours but failed to move. She has fractured her left ankle badly.

Without further delay she called her husband and Vineet reached home in an hour. Finding Priya in such a condition, he called the doctor immediately. The doctor prescribed her complete rest and also advises against moving her left leg to avoid further dislocation. It was decided that moving her to the hospital would be too difficult and the nearby hospitals do not have proper accomodation available for her. The doctor setup the process in order to make her normal so that she can be shifted to the hospital later for complete medication.

It took her complete 4 days to recover thanks to the love and attention of her husband. Vinnet applied to claim the expenses of a private insurer as he was already aware of the benefits of domiciliary hospitalisation. Luckily, there was a provision in the plan to use 15% of the total sum assured in his family floater plan.


Case-II

Hemant Adhikari is a civil engineer and spends a lot of the time in the week on site-visits at remote places. This has exhausted him badly and he fell ill with a severe infection in the upper respiratory tract. The doctor advises him complete rest and a balanced diet with proper medication for a speedy recovery. He recovers in a week and immediately claim for the expenses without understanding the clauses of domiciliary hospitalisation. Thus his claim is rejected.

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