Introduction

Ever heard of ‘cataract couching’?

Well, this is one of the earliest surgery approaches to a cataract issue. Practiced during the Renaissance Age, the Cataract Couching approach did not bode well for the patient. Abysmal outcomes, including clinical blindness due to this surgery, raised red flags during this Age.

Thankfully, centuries later, today, cataract surgeries have become risk-free surgery demanding even less than 24 hours of hospitalization and ensuring a 100% success rate.

This seems like a moment of immense pride for the medical industry, and should be celebrated in all ways possible, right?

But here’s the thing - this drastic progress in the medical sector is posing a hurdle in the path of the patients as they find their insurance partners reluctant to sponsor and cover this treatment.

Reason?

  • The treatment requires less than 24 hours of hospitalization
  • It is relatively common among the aged and carries a higher possibility of payout.

But, such misleading and calculative clauses across the T&C of the insurance policies are a massive contradiction to the IRDAI’s (Insurance Regulatory and Development Authority) initiatives to boost the penetration of the insurance sector into the rural market across India.

Subsequently, the authoritative body has requested insurance companies to include a  specific feature in their policies - daycare treatment. This would allow patients to reap the benefits of the advancement of medical science sans the worries of the financial burden.

After all, this is precisely why health insurance plans came into being - to offer a financial security net to all seeking access to premium healthcare services.

So, what exactly is daycare treatment included in multiple health insurance policies? Here, take a look -

What is Daycare Treatment in the Health Insurance Sector?

Thanks to years of experiments, research, and hard work on the part of the medical industry, over the last few years, treatment of a few conditions has become convenient and demands far less time involvement.

Such advancements have ensured the treatment of some ailments at a faster pace, often requiring less than 24 hours of hospitalization. But, unfortunately, most health insurance covers do not offer financial aid unless the policyholder has been hospitalized for a minimum of 24 hours.

However, in some insurance policies from some of the best health insurance providers across India (in case you are looking for some of the top providers across India, you can go ahead and read our blog -

Best Health Insurance Companies in India

-who prioritize policyholders over their profits, daycare treatment is an obvious inclusion.

While multiple medical procedures do not require 24 hours or more of hospitalization, insurance providers do not often cover all of them. So, when availing of an insurance policy for yourself, ask your insurer

  1. Does my insurance policy offer daycare treatment coverage?
  2. What daycare treatments are covered under this feature? (Take a look at the section below for reference to what you should expect from your daycare treatment coverage.)

What Qualifies as Daycare Treatment in the Health Insurance Policy?

CASE 1: Evans walks into the ER with terrible pain in his wrist, writhing in pain. The doctors conduct some tests and tell him he has a sprain that requires a sling and some over-the-counter pain relief medications. Not covered under Daycare treatment.
(covered under the OPD feature in some policies)
CASE 2: Samara faces certain issues with her visions. She goes to the hospital and comes to know that she needs to have her cataract operated on at the earliest. She gets hospitalized a couple of days later and walks out 6 hours later with a patch on her eyes, a dark glass, and some medications. Covered under the Daycare Treatment feature

While in both these cases, the insured individual did not require more than 24 hours of hospitalization, one gets financially covered under the health insurance policy, while the other doesn’t. Why is this so?

For any illness to be covered under daycare treatment, the following 3 factors are mandatory -

  1. Hospitalization
  2. The treatment has to be medically necessary
  3. The treatment should require less than 24 hours of hospitalization because of advancements across the medical field.

When policyholders are told they can have coverage for these procedures, they are encouraged to avail of health insurance policies. This suffices the IRDAI requirement of spiked insurance penetration nationwide since the no-hospitalization medical expenses supersede the hospitalization charges.

While this is the key benefit that influences the availing of daycare treatment coverage, there are multiple other benefits.

Pros and Cons of Daycare Treatment

  ADVANTAGES Of DAY CARE TREATMENT

  1. Cashless treatment options

Any procedures that fall under the daycare treatment feature are planned well in advance. This makes it feasible for policyholders to look for the nearest and best network hospital.

Hospitalization in these partner hospitals helps the insured avail of a cashless treatment process. All that one has to do is inform the insurer about the situation in advance.

2. Convenient claim process

The claim and settlement process for daycare treatment procedures is the same as that of in-patient hospitalizations.

Considering that you have chosen one of the top insurance providers across the country, you can now opt for either a cashless treatment process (across network hospitals) or a reimbursement option (for non-partner hospitals).

3. Easy access to premium healthcare

With such a supportive feature on your side, you can solely focus on the best possible healthcare service you need and not on the financial aspect of this treatment. This ensures that you don’t compromise with your treatment for the sake of the financial strain that it might put on your savings.

  DISADVANTAGES Of DAY CARE TREATMENT

  1. Limited provider network

Insurance providers usually have a limited range of partnered hospitals in the case of daycare treatments. This limits your options significantly to opt for a cashless mode of coverage.

However, even if you opt for a hospital that has no tie-up with your insurer, your bill will be reimbursed (provided you have met all the required eligibility criteria).

2. Complicated eligibility criteria

The eligibility criteria for the daycare feature are relatively more complex as compared to the other perks offered by health insurance plans. Usually, insurance providers demand that you have a referral from a primary care physician, and/or a diagnosis of a medical condition (that is enlisted in their queue of inclusions), and more.

3. Pre-existing illness restrictions

Even the best insurance providers across the country have a long list of ailments that are covered under their Daycare treatment feature. However, despite how long that list of inclusions is, there always are loopholes in the form of exclusions. So, while availing of a health insurance plan that offers this perk, pay equal, if  not more attention to exclusions as is provided to its inclusions.

4. Caps on coverage

Since this is just a solo feature on your availed plan, there is a cap on the coverage offered for this kind of treatment. If your medical bill incurred during a daycare procedure exceeds the threshold amount assigned, the policyholder ends up paying it out of their pockets.

How to Avail Daycare Treatment in Your Health Insurance Policy?

Availing a daycare treatment coverage in your plan might be just as simple as asking your insurer if it is included in the plan you are opting for and requesting its inclusion in case it’s not.

However, we always say when choosing any feature for your plan, make sure that you know all the nitty-gritty details of the same. This is a long-term financial investment for you that will effectively cushion your financial burden during medical emergencies.

So, when choosing a daycare plan-integrated insurance cover, consider a few factors and acknowledge how you would need to file a claim for such procedures -

What factors should you consider when choosing a daycare plan?

  • Exclusions & Inclusions

As stated above, while many procedures fall under daycare treatment, not all insurers provide and include all these. So, the best way forward would be -

STEP 1: Schedule a call with one of the expert Insurance Advisors.

STEP 2: Seek their informed guidance regarding the inclusions and exclusions of the policy feature.

STEP 3: Jot down the top 3 insurance providers who best cater to your medical requirements.

STEP 4: Head to our Health comparison tool- and finalize your decision.

  • Disease-wise sub-limits

Even if insurers offer a substantial amount of coverage for daycare treatment, there are often caps on some diseases that restrict the amount that the insurance provider will cover.

For example,

You walk into a partner hospital for an angioplasty, knowing that it is a daycare procedure and that you will get a complete cashless treatment (because you haven’t opted for a copayment option).

However, later, during discharge, you come to know that your insurer will only be paying INR 20,000 since this is their cap for cardiac-related procedures. And since the hospital bill is INR 30,000, you spend the residual amount of INR 10,000 from your pocket.

So, try and avoid plans that have disease-wise sub-limits on their coverage.

  • Network hospital

Opt for a plan whose daycare treatments can be accessed over multiple network hospitals (should be close and provide premium health services).

How to file a claim for a daycare procedure?

  • CASHLESS CLAIM

STEP 1: Choose a network hospital for the procedure & inform your insurer about the situation before hospitalization.

Step 2: The insurer cross-checks the treatment, the terms, conditions, and the course of treatment to see whether this is covered under their daycare feature across the availed health insurance policy.

STEP 3: The hospital receives the charges of the daycare process from your insurer, as had been decided over your policy.

  • REIMBURSEMENT CLAIM

STEP 1: Opt for a non-network hospital of your choice and inform your insurer prior to hospitalization.

STEP 2: Pay for the daycare treatment process

STEP 3: Submit all the medical bills and health records for the hospitalization with your insurer to raise a reimbursement claim.

Frequently Asked Questions:

  1. Should I avail of daycare treatment in my health insurance package?

Daycare treatment is a lucrative feature for health insurance policyholders. However, before availing of this policy, you need to be precisely updated about the pros and cons of the feature and weigh them out.

PROS:

  • Assured ease of access to premium healthcare services from the comfort of your home.
  • Access to quality medical caregivers.
  • Easy claim settlement and reimbursement process.
  • Cashless treatment options are also available.

CONS:

  • The feature covers only specific ailments and treatment types.
  • There are restrictions on the fund offered as coverage for the daycare treatments.
  • Patients do not have access to all top-notch medical equipment.
  • There are caps on the number of days for which the treatment is financially covered.

You should also take into consideration whether the feature stands beneficial to your medical and financial requirements.

2. Can senior citizens avail the benefits of daycare treatment in their health insurance coverage?

Yes, some health insurance plans do extend their daycare treatment benefits to senior citizens. However, considering their age and higher risks of increased health complications, there might be certain additional caps and restrictions on the exclusions for the feature and the insurance coverage offered. Consult our experts before buying any policy.

3. Are daycare treatment and OPD the same?

No, they are not. The major difference between the two is that while daycare treatment demands mandatory hospitalizations (less than 24 hours), OPD covers are valid for treatments requiring no hospitalization.

DAYCARE TREATMENT
Example: chemotherapy, hernia, appendectomy, cataract, etc.
OPD COVER
Example: Sprains, fractures, health checkups, etc.
Mandatory hospitalization No hospitalization
Coverage offered can extend up to the total sum insured Coverage has a limit, as has been proposed by the insurer.


4. Are COVID-19 treatments covered under daycare?

It is not completely impossible that a daycare hospitalization feature offers coverage for COVID-19 home treatment.

However, considering the volatile nature of the pandemic, insurance providers are not always consistent regarding their inclusion of COVID-19 treatment into their plans. So, the best way forward would be to ask your potential insurer regarding the coverage prior to availing of a health insurance policy.

5. What are the benefits of daycare treatment options in health insurance?

The daycare treatment feature across health insurance policies offers a diverse range of benefits to you, the policyholders -

  • Financial coverage for ailments that are necessary yet require less than 24 hours of hospitalization due to the advancements in medicine and technology.
  • Easy claim and settlement process that can be availed over two options - reimbursement across a non-partner hospital or cashless over a partner hospital.
  • Since daycare procedures are planned and not untimely emergencies, one can choose a partner hospital and enjoy a completely cashless treatment as specified in the policy cover.

PLEASE NOTE: The complete cashless treatment holds only if the policyholder hasn’t opted for a copayment option. You can learn more about whether you should opt for a copayment option or not in our article.