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Day Care Treatments Under Health Insurance

Health Insurance Guidelines

There are many risk-free surgeries and treatments like cataract, fistula, angiography etc., which do not require the patient to stay in hospital for more than 24 hours. The ease of these treatments has made it easy for people to go through such procedures without any health hassle. However, since these treatments do not require 24-hour hospitalization, it was difficult to get them reimbursed from the insurance company earlier.

However, IRDAI (Insurance Regulatory and Development Authority) stated that insurance companies should boost penetration of health insurance in rural areas. Thus, IRDAI sought insurers to include the Day Care Treatment feature under their health insurance policies.  Let us understand day care meaning in health insurance, in this post.

What is Day Care treatment in Health Insurance?

The advancements in the medical industry have made it possible to get the treatment of some illnesses at a fast pace which normally doesn’t require the patient to stay in the hospital for more than 24 hours. These procedures are known as Day Care treatments or procedures. For instance, cataract surgery, nasal sinus aspiration, and so on.

What makes a treatment qualify as a Day Care Procedure?

Below are the points that qualifies a condition as day care treatment in health insurance

  • The treatment should take less than 24 hours of hospital stay for the patient
  • The patient is admitted in the hospital but not required to stay beyond 24 hours
  • The treatment should be an important medical process
  • Not all short-term treatments come under day care treatment
  • Day care treatment include surgeries, operations etc., that need less than 24 hours hospitalization because of advancement in healthcare technology
  • It also includes chemotherapy, dialysis etc.
  • However, Day Care procedures shouldn’t be confused with OPD cover
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Why is Day Care Treatment Important in Health Insurance?

  • Expenses of Day Care treatment that doesn’t require proper hospitalization are quite high
  • There are many critical illnesses such as kidney related ailments and cancer where the patient undergoes day care procedure like chemotherapy and dialysis that require frequent and large expenditure
  • The technological advancement in medical sciences has improved the treatment of many diseases and they require less than 24-hours of hospitalization

Do all Health Insurance Companies Offer Day Care Coverage under their Policies?

In the past, most health insurance policies covered the cost of hospitalization beyond 24 hours. Hence, day care facilities were not considered under these policies. However, with technological advancements, many health procedures can be operated and treated within a short time duration. Moreover, such patients were not required to be hospitalized for more than 24 hours in the hospital.

Looking at the scenario and the need of the moment, IRDAI has introduced the Day Care procedure under health insurance policies.

What is included and what is excluded under Day Care Procedure?

Inclusions of Day Care Procedure

The day care treatments that are covered by health insurance policies are related to surgeries or operations which need the policyholder to stay in the hospital for less than 24 hours. For instance, eye surgery/cataract, dialysis, chemotherapy, and so on.

Exclusions of Day Care Procedure

All the short duration medical procedures are not covered under day care procedures. There are some treatments that require OPD treatment. OPD means in the hospital Outpatient Department and the treatments that come under OPD are not considered as day care procedures.

For example, minor injuries, seasonal diseases, and health check-ups done on a regular basis and so on. These procedures do not need surgery and hence they are not covered as day care treatments.

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Day Care Treatment List

Below are some day care procedures that are covered under Day Care treatment of health policies:

Treatment Procedure
Eyes Cataract
Throat Adenoidectomy
Nose Septoplasty
Rectal Piles/fistula
Gastro Appendectomy
Others Angiography, Chemotherapy, Radiotherapy

Advantages of Day Care Procedure

When it comes to day care procedures, they are not only bound by the operations and surgeries. In fact, day care treatments involve other healthcare expenses like diagnostics, medications, health check-ups, injections and so on. When you count all such these together, the total expense of a particular treatment goes much higher. In such a situation, your health insurance comes to your rescue.

How to Raise Claims for Day Care Procedures?

Like you fill the claim form in case of in-patient treatment, the same process is followed for filing claims for day care procedures. You can either go for a cashless process of settling claims or may seek the reimbursement claim settlement method.

Cashless claim process

  • Here, you first have to decide about the network hospital where you want to get the day care procedure done and let the insurer know about it in advance
  • The hospital will also send the same information to the insurer and confirm that the day care treatment comes under the purview of the plan
  • The final bill of the hospital will be covered by the insurance company as per the terms of the day care procedure coverage

Reimbursement claim process

  • Here, you can pick any non-network hospital to get the treatment done and inform the insurer accordingly before getting the procedure done
  • Now, once you get the treatment done pay all the dues to the hospital from your pocket
  • Now, submit the soft copies of the relevant documents like discharge summary, bills etc. to raise the claim

What is OPD meaning? Difference Between Day Care and OPD

The full form of OPD is the Outpatient Department. Under OPD, patients visit hospitals if they suffer from any disease so that they can consult the issue with the doctor and start the treatment. Here are some key differences between OPD and Day Care Procedure:

Features Day Care Treatment OPD Treatment
Hospitalisation  Compulsory hospitalisation of less than 24-hour  Hospitalisation not required
Extent of coverage Coverage offered to the extent of complete sum insured Coverage offered up to a limited sum depending on the policy
Procedures Cataract surgery, angiography, chemotherapy, etc. General medical consultation, health check-ups, minor injuries etc.

Frequently Asked Questions

Day care procedures are generally included under health insurance policies and are not required to be opted separately.

Yes, day care procedures cover all insured individuals including senior citizens.

There is a list of day care procedures covered under most health insurance policies and it depends from insurer to insurer.

Day-care treatments can usually be claimed up to the sum insured amount.

You can use google or other such search engine platforms to find a day care centre and the fee for particular procedures.

* Rs. 245/month is the starting price for a 5 lac health insurance for an 25-year-old male, with no pre-existing diseases.
*! Rs. 334/month is the starting price for a 10 lac health insurance for an 25-year-old male, with no pre-existing diseases.
*@ Rs. 12/day is the starting price for a 5 lac family health insurance for an 25-year-old male and 22-year-old female, with no pre-existing diseases.
*# Rs. 12/day is the starting price for a 5 lac health insurance for an 25-year-old male, with no pre-existing diseases.
*$ Rs. 600/month is the starting price for a 20 lac health insurance for an 25-year-old male, with no pre-existing diseases.
*^ Rs. 12/day is the starting price for a health insurance that covers coronavirus for an 25-year-old male, with no pre-existing diseases.