Domiciliary Hospitalisation in Health Insurance

Conditions for Domiciliary Hospitalisation Coverage

For the claim to be accepted, the treatment must meet specific, strict conditions:

• The treatment must be medically necessary and prescribed by a qualified physician.
• The medical expenses must be reasonable, necessary, and incurred during the policy year.
• The treatment at home must continue for at least 3 consecutive days (72 hours).
• The patient must be confined at home because their condition prevents them from being moved to a hospital, or because there are no available hospital beds or necessary medical facilities.

Domiciliary hospitalisation is indicated when a patient’s condition can be managed safely at home, thereby avoiding a prolonged hospital stay. Medical professionals typically determine the need for domiciliary hospitalisation, subject to the terms and conditions of the health insurance policy. In health insurance, domiciliary hospitalisation is allowed only under certain conditions specified in the policy.

What is Not Covered Under Domiciliary Hospitalisation Benefit? 

Any medical expenses incurred for the treatment of the following diseases shall not be payable under the domiciliary hospitalisation:

• Arthritis, Gout, and Rheumatism.
• Asthma.
• Bronchitis.
• Chronic Nephritis and Chronic Nephritic Syndrome.
• Diarrhoea and all types of dysentery, including Gastroenteritis.
• Diabetes Mellitus and Diabetes Insipidus.
• Epilepsy.
• Hypertension.
• Influenza, cough or cold.
• All Psychiatric or Psychosomatic Disorders.
• Pyrexia of unknown origin.
• Tonsillitis and Upper Respiratory Tract Infection, including Laryngitis and Pharyngitis.

Who is Eligible?

Eligibility for domiciliary hospitalisation cover in health insurance is determined by both the patient's medical condition and the policy terms. It is eligible when a doctor certifies that the patient needs medical care at home due to critical illness, mobility issues, chronic conditions, or post-surgery recovery. It also applies when hospital beds or resources are unavailable. Eligibility is always subject to policy terms.

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How Does Domiciliary Hospitalisation Work with Your Insurance?

The provision of domiciliary hospitalisation cover generally involves a structured process to ensure the treatment is legitimate and medically sound. Understand how it works:

Doctor’s Evaluation

A qualified doctor examines the patient to confirm that home treatment is necessary and safe when hospital admission isn’t possible.

Home Medical Setup

Once approved, the doctor arranges the required support, such as nursing care, monitoring equipment, or periodic check-ups, to provide hospital-level treatment at home.

Notify the Insurer

The patient or family must inform the insurer of the home treatment and submit supporting documents, such as a doctor’s certificate, medical reports, and bills, to initiate the claim.

Claim Approval & Reimbursement

The insurer reviews the claim, verifies it in accordance with the policy terms, and reimburses the eligible domiciliary hospitalisation expenses.

How to File a Claim?

Filing a claim for domiciliary hospitalisation in health insurance generally involves the reimbursement process. Policyholders must diligently follow the prescribed steps to ensure the swift processing of their domiciliary hospitalisation expenses.

• Review Coverage: Before initiating treatment, check if the domiciliary hospitalisation benefit is included and confirm its coverage amount. Almost all insurance policies at Care Health Insurance have domiciliary hospitalisation coverage as an in-built feature.
• Obtain Doctor's Recommendation: Ensure the treating physician prescribes domiciliary hospitalisation, confirming its medical necessity and duration (at least 72 hours).
• Intimate the Insurer: Notify us of any illness or injury that may lead to a claim. For us, claim intimation must be made within 48 hours of the event, providing all relevant details.
• Document Everything: Collect all relevant documents, including medical records, bills, and prescriptions, from the commencement of home care.
• File the Claim: Complete the health insurance claim form accurately and attach all supporting documentation.
• Submit Timely: Submit the completed claim form and necessary documents within the insurer’s specified timeframe, typically within 30 days from the date of discharge from the hospital or the actual date of loss for non-hospitalisation benefits.
• Follow Up: Track the claim status and provide any additional information requested by the insurer for assessment.

What are the Documents Required to Claim?

Proper and accurate documentation is a condition precedent to the insurer's liability, ensuring a smooth process for claiming domiciliary hospitalisation expenses. To register a claim for domiciliary hospitalisation cover, policyholders must submit the following documents to the Company:

• Claim Form: A duly filled and signed claim form by the insured person
• Identification Proof: A copy of the insured person's photo ID and address proof.
• Medical Recommendation: The medical practitioner's first consultation report and the referral letter advising domiciliary treatment or hospitalisation
• Bills: Original numbered bills/receipts from the Medical Practitioner, and licensed pharmacies/chemists
• Diagnostic Reports: Original pathological/diagnostic test reports/radiology reports, along with payment receipts, supported by the doctor's reference slip
• Additional Documents: Any other document required by the company to assess the claim

Pro Tip: For a claim to be registered, all required information and supportive claim-related documents must be furnished within the stipulated timelines, and they must be explicitly made in the insured person's name.