As India’s active Covid-19 cases have crossed the 7,000-mark, individuals must ensure that their health insurance policy includes outpatient department (OPD) and consumables cover. They should also assess whether the policy includes home care or domiciliary hospitalisation.
An OPD cover will ensure that the insured and his family are protected even when hospitalisation isn’t required, by covering doctor consultations, diagnostic tests, and medications, which can be quite expensive. Even non-medical expenses —like PPE kits, gloves, or even room charges—can add up significantly in case of hospitalisation for Covid-19 treatment.
It is essential to examine that the policy has sufficient sum insured to cover high treatment costs for Covid-19, including ICU charges, oxygen support, and post-hospitalisation expenses. Most of the recent policies also include coverage for home quarantine and telemedicine consultations, which are valuable in managing mild cases of Covid-19 at home.
Domiciliary hospitalisation
Domiciliary treatment for Covid is covered under most existing health insurance policies. Domiciliary treatment, meaning treatment at home, is provided when hospitalisation is not possible due to a shortage of beds or the patient is immobile. The insured must get a doctor’s prescription recommending home treatment and inform the insurer immediately or through the third party administrator (TPA).
For claims, the insured must submit the claim along with all supporting documents, including the doctor’s certification, to the insurer within the specified timeframe. “It is advised to keep medical records, diagnostic reports, and medicine bills, safely at the time of submitting the claim if it’s reimbursement-based, or coordinate for cashless care if their insurer offers it,” says Siddharth Singhal, business head, Health Insurance, Policybazaar.com.If your current policy doesn’t include this coverage, it’s advisable to contact your insurer to explore the possibility of adding it or switching to a product that provides for it.
Exclusions in policies
While most health insurance policies offer Covid-19 coverage, there are a few essential exclusions that policyholders must be aware of to avoid claim rejections or unexpected out-of-pocket expenses. Some policies may not cover Covid-19 treatment if the infection was contracted under specific circumstances, such as travel to high-risk areas or due to negligence.
Most health insurance policies have a waiting period of 15 to 30 days from the date of policy issuance, during which, if the insured contracts the virus, the insurer may reject the claim. Another key exclusion is home quarantine without medical supervision. While many policies cover home care treatment, they typically require a prescription from a registered medical practitioner and ongoing monitoring by a healthcare provider. Self-isolation without medical documentation or supervision is usually covered under OPD coverage.
Bhaskar Nerurkar, head, Health Administration Team, Bajaj Allianz General Insurance, says pre-existing conditions may also affect Covid-19 claims. “If the insured has underlying health issues that were not disclosed at the time of policy purchase, and these conditions worsen due to Covid-19, the insurer may deny or restrict the claim,” he says.
However, under IRDAI guidelines, insurers are not allowed to exclude more than 16 specific pre-existing conditions permanently from a health insurance policy.
Additionally, diagnostic tests done solely for screening or evaluation purposes—without subsequent hospitalisation or treatment—are generally excluded. This means that if you get tested for Covid-19 as a precaution and are not hospitalised, the cost of the test may not be reimbursed.
Expenses related to rest, rehabilitation, or respite care—such as prolonged bed rest at home or in a nursing facility—are also excluded unless they are part of a prescribed treatment plan. Similarly, experimental or unproven treatments, including specific alternative therapies, are not covered unless specifically mentioned in the policy.
Top-up cover
A top-up or a super top-up policy is one of the most cost-effective ways to enhance your overall health coverage. It kicks in once your base policy threshold is crossed and covers any additional medical expenses beyond that limit. “A top-up plan can act as a safety net once a certain threshold is crossed. Such a cover is more affordable than increasing the base cover,” says Sarita Joshi, head, Health and Life Insurance, Probus.