Health Insurance & 24 hours Hospitalization Clause.

We as an insurance brokers deal with both retail as well as corporate mediclaim policies. And as a standard procedure, we make power point presentations to all corporate clients with regard to the terms and conditions of their mediclaim. However there is one point we add into all our presentation irrespective of the client, coverage terms and the insurer. That is the 24hours hospitalisation requirement clause. Yes, majority of the health policy holders are aware that a claim is admissible under their policy only if there is 24hours or more of hospitalisation. But the question is Does a 24 hospitalisation make you automatically eligible for claim? The answer is no!

The primary condition is that hospitalisation should occur when the policy is valid or in force and the medical condition is covered by the policy. But most importantly, hospitalisation should be for curative purpose with active line of treatment and not for observation, evaluation or diagnostic purposes. We see cases where the patient is admitted for 2-3 days for observation and evaluation only. X-rays, MRI scans, blood tests etc would be prescribed and done by the hospital, but at the end of these tests, the patient would be discharged with mere painkillers. In such cases, the insurance company will not pay the claim.  The non admissibility of such hospitalisation is clearly mentioned in every insurance company’s policy wordings. Take the pains to read through your full policy wordings.

As a corollary, the treatment for the ailment or injury should be such that it cannot be done as an Out-Patient and requires admission as inpatient for a minimum period of 24 hours. The line of treatment should be proven and accepted and not experimental or unproven.

The argument that we usually encounter with regard to this condition is that ‘the doctor asked us to be admitted’. The doctor may ask you to get admitted for monitoring or diagnosis. He is not under any obligation to meet the requirements of your mediclaim policy by ensuring admission only for valid treatment. The hospital is a business house and would always prefer to admit patients. As a precaution, don’t flash your insurance card or announce at the onset itself that you have insurance coverage and ask whether an admission is really necessary.

Relaxation of the minimum period of 24 hours is allowed for certain procedures or treatments like Cataract, Dialysis, Chemotherapy, etc. Your policy document would have the exact list of these procedures / treatments. So don’t try to stretch a hospitalisation to correct 24 hours. 

And understand above all, that an insurance company does not reject a genuine claim. The medical documents are scrutinized by a panel of doctors in every insurance company. Moreover, unreasonable rejection of claims will always affect the brand name of an insurance company and reduce their market share. No insurer would purposefully engage in such self-destructive acts.