Day Care Treatment in Group Health Insurance

Employees covered under a group health insurance plan get coverage for the daycare treatments. Day care treatments refer to the treatments that require less than 24 hours of hospitalisation such as eye surgery, chemotherapy, etc. However, not every group health insurance covers daycare treatments therefore you must check the daycare treatments covered under your group plan.

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Day Care Treatment Meaning

In the daycare treatment under group insurance, the insured employee gets coverage for the medical procedures that do not require more than 24 hours of hospitalisation because of modern technology. Also, insured employees should not get confused between daycare procedures and OPD consultations for sprains, fever, cold, etc., they do not fall under the daycare category.

Importance of Day Care Coverage

Getting daycare treatment for employees under a group health insurance plan can provide you with financial support for medical procedures that do not require more than 24 hours of hospitalisation but can put a big hole in your pocket. 

  • Easy Claim Process: Insured employees can get cashless claims or reimbursement for the expenses incurred in daycare treatment.
  • Wide Hospital Network: An insured employee gets access to a wide network of hospitals registered with the insurance company.

Daycare Treatments Covered Under Group Health Insurance

Usually, all group health insurance policies provide coverage for daycare treatments. However, the list of treatments may vary from one insurer to another.

Treatment Operations/Procedures
Nose Septoplasty
Gastro Appendectomy
Eyes Cataracts
Throat Adenoidectomy
Rectal Fistula/Piles
Others Radiotherapy, Angiography, Chemotherapy

*Note that this is an illustrative list. For detailed information, you can go through your policy documents.

Exclusions under Day Care Treatment

Day care treatment for employees under group health insurance does not cover any short-term medical procedures. Treatments that come under the Outpatient department (OPD) are not covered under daycare treatments.

For instance, consultation with a doctor for minor injury, fever or cough is not covered under daycare treatments. It is because such procedures do not require any surgery hence these OPD procedures are not covered under daycare.

Daycare Treatment Vs OPD Treatment Cover

Here are a few factors that differ Daycare treatments from OPD treatments

Factors Day Care Treatment OPD Treatment
Hospitalisation Less than 24 hours hospitalisation is mandatory No hospitalisation required
Coverage Extent To the total sum insured extent Up to the specified sum in the insurance documents
Examples of Procedures Chemotherapy, Cataract surgery, Angiography Medical consultation for health checkup, seasonal illness, injury, etc.

Eligible Medical Treatments under Daycare Procedure

Here are those three factors that make a medical treatment eligible as a daycare treatment.

  • The medical procedure or treatment must be medically necessary.
  • The patient has to be admitted to a hospital for treatment.
  • The patient must not be admitted for more than 24 hours.

Claiming Process for Daycare Treatment

The claiming process for day care treatment in group mediclaim can be done in two ways. Cashless and reimbursement. Let us tell you about both:

Cashless Claim through Network Hospital

  • Step 1: To get a cashless claim, the insured employee must get the treatment done in one of the network hospitals and inform the insurer before hospitalisation.
  • Step 2: Then the hospital will confirm the treatment being done and come within the terms and conditions of the daycare treatment cover.
  • Step 3: Then the insurer will make the payment to the hospital and settle your cashless claim.

Reimbursement Claim through Non-network Hospitalisation

  • Step 1: Get admitted to any of the non-network hospitals and inform the insurer of the same.
  • Step 2: After the treatment, make the payment out of pocket.
  • Step 3: Ask the insurer for the claim form and submit it with the required documents to raise the reimbursement claim.
  • Step 4: The insurer will settle the claim within the specified days in the insurance documents.

Consider These Things While Purchasing

Here are several things that you can consider while purchasing a group health insurance plan that provides daycare cover:

  • Total Sum Insured: Make sure that the sum insured you opt for will be enough for daycare treatment expenses.
  • Inclusion & Exclusion: Read the policy documents carefully to under the daycare treatments that are covered and not covered under the policy.
  • Network Hospital List: Go through the list of network hospitals and shortlist the nearby hospitals to get cashless claims easily.

Conclusion

Protect your employees with group health insurance that covers daycare treatments. It will take the expected financial burden off of their shoulders. This will eventually help the company in retaining old employees and attracting new ones as for employees this is one of the features, not all companies provide.

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Written By: PolicyBazaar - Updated: 08 August 2022
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