Times of India
18 May 2011
By Preeti Kulkarni

Insurance cos offer cover for various day–care procedures to lure customers. Here’s how you can benefit from it
Any discussion on health insurance mostly centres on regular hospitalisation expenses reimbursed by health insurers. Many people assume that only costs incurred during a prolonged stay at the hospital qualify for reimbursement. This is despite the fact that insurance companies are paying for a host of procedures where the patient is not required to spend 24 hours at a hospital.

In fact, several insurers have the number of such treatments covered by their policies as the key selling point. In industry parlance, these are termed ‘day–care procedures’. While the awareness about such procedures is increasing and many insurance–seekers make it a point to scan this aspect while choosing a policy, they are ignorant about the correct approach. Here’s what you need to know about day–care procedures to help you make the right decision.

Day Care
Day–care procedures do not entail 24–hour hospitalisation, but that does not mean they are any less expensive. In fact, the total cost of radiation and chemotherapy or dialysis may well exceed the expenses incurred on say a hernia surgery. The number and type of day–care procedures covered depends on the insurance company you opt for.

"The list of day–care procedures covered is being expanded, consequent to technological advances in medical treatment," says Sanjay Datta, head, health insurance, ICICI Lombard General Insurance. Due to such advancements, many treatments that necessitated hospitalisation earlier can now be completed within a day. "Cataract, for instance, entailed more than 24 hours’ hospitalisation earlier, but can now be completed in 12–13 hours," says Mahavir Chopra, head, e–business, medimanage.com. The list of procedures covered could be lengthy, but usually treatments like cataract, tonsillectomy, dialysis, chemotherapy, etc, will qualify as day–care procedures.

The Numbers Game
While insurance companies – both life and general – flaunt the number of day–care procedures their policies cover, it would be unwise to use just this as a comparison tool. You need not necessarily opt for the policy that promises the highest number of such admissible ailments. "Many people make the mistake of comparing the number of daycare procedures covered while looking for a policy. They tend to get confused by the numbers put out, but this aspect is not strictly comparable," says Chopra.

If one company claims that it covers 162 procedures while another undertakes to pay for 148 treatments only, it does not necessarily mean that the former is offering you a better deal. The catch, like always, lies in the detail. "Some companies may promise to cover say eye surgery, which is a broader definition. On the other hand, some other company may divide this further into several ailments, thus resulting in a larger number, but with the possibility of leaving out certain treatments in the process.

Public sector insurers, for instance, include a broader definition even though the number of procedures covered is smaller," he points out.

Now, if a new treatment procedure enters the scene in future, those owning policies with narrower and specific definition of what is admissible may stand to lose out due to the grey area created. If you have to compare, go for the policy that offers a wider definition of illnesses covered.

Claims Filing Procedure
The procedure is largely similar to the one for regular hospitalisation claims. "There is no difference, except that some insurance companies may request intimation in advance for planned daycare procedures," says S Narayanan, MD and CEO, Iffco–Tokio General Insurance.

Cashless facility, too, is extended to day–care procedures. "Since most day–care procedures are done on a planned basis, the approval for cashless treatment usually happens prior to admission in hospitals and, in most cases, subsequent addendums are not required," says Datta of ICICI Lombard. "In the case of 24–hour hospitalisation claims, however, the cashless approval is sought either prior to admission or while the customer is admitted and there may be subsequent addendums depending on the diagnosis and complications of treatment. Otherwise, the process for both is more or less similar."

Approving Claims
The sanction could be smoother and quicker for day–care procedures. "Since a lot of day–care procedures are surgical, the cost of treatment is easier to standardise and, hence, cashless approvals are quicker than for regular hospitalisation expenses. And, because the assessment process is simpler, the reimbursement process is also faster," says Datta.

Pre and Post–Hospitalisation Expenses
In addition to regular hospitalisation costs, most policies also cover, subject to certain parameters, expenses incurred 30 days prior to hospitalisation and 60 days post discharge. Policies undertake to fulfil this commitment for daycare treatments as well. Therefore, any expenses incurred by the insured for medication and medical care required during the period of treatment will be reimbursed by the insurance company.

"Provisions for pre– and posthospitalisation benefits do not generally change for day–care procedures. However, insurance companies may restrict the number of days for which such benefits may be offered," says Narayanan. "In case of radiation or chemotherapy treatment covered under day–care procedure, the claim for post–chemotherapy expenses will have to be considered unless there is specific restriction mentioned under the policy."

Benefit, Indemnity–Based Plans
Both life and general insurance companies offer benefit as well as indemnity–based policies. The amount of claim that will be disbursed would also depend on whether you have opted for a benefit or an indemnity (or reimbursement) policy.

"If the benefit policy promises to reimburse expenses only on a per–day basis, the amount is likely to be small and, thus, you could be at a disadvantage in the event of your actual expenses exceeding this limit. In this regard, indemnity–based policies score over their benefit counterparts. However, benefit policies that assign fixed reimbursement sum to specified treatments could still be worthwhile," says Chopra.

Coverage for day–care procedures is just one aspect among the many parameters you need to consider while buying health insurance. However, the long–drawn–out (and expensive) process for procedures like chemotherapy or radiation makes it imperative for you to put day–care–related details high on your wish list of policy features while choosing a health plan.