What are Medical Expenses in Health Insurance?

What are Medical Expenses?

Medical expenses refer to the costs incurred on the diagnosis, treatment, cure, mitigation, or prevention of disease or injury. It is the charges paid to avail various medical treatments and facilities, such as hospitalization expenses, doctor consultation fees, diagnostic test charges, medicine costs, surgery costs, ambulance charges, etc. All health insurance plans are designed to cover planned and emergency medical expenses.

Which Medical Expenses are Covered in Health Insurance?

Most standard health insurance policies in India cover the following medical expenses:

1. Hospitalization Expenses

   Hospitalization expenses are the primary expenses incurred during hospital admission. Most medical insurance plans pay for hospitalization expenses like room rent, ICU or ICCU charges, surgery costs, doctor/specialist fees, OT charges, medical equipment, etc.

2. Pre-Hospitalization Expenses

   Mediclaim insurance covers the healthcare costs incurred before you are admitted to the hospital. Typically, insurers cover these pre-hospitalization expenses incurred for specific number of days, i.e.30, 60 or 90 days, before hospitalization. Pre-hospitalization costs consist of diagnostic tests, medical consultations, medicines, etc., availed before hospitalization.

3. Post-Hospitalization Expenses

   Post-hospitalization expenses refer to the medical expenses incurred after the discharge from the hospital for follow-up care, such as follow-up consultation fees, physiotherapy charges, medicine costs, etc. Insurers usually cover these expenses for up to 60, 90 or 180 days post-discharge.

4. Day Care Treatments

   Medical advancements have enabled many procedures to be completed in a few hours without the need for an overnight stay at the hospital, such as cataract surgery or chemotherapy. These treatments or procedures are known as day care procedures. Mediclaim policies cover the cost of day care treatments even if they do not involve a 24-hour hospitalization.

5. Domiciliary Hospitalization

   If you or your elderly member cannot be moved to a hospital due to a critical condition or lack of hospital beds, domiciliary treatment at home is administered. Medical expenses incurred on domiciliary hospitalization are covered by health insurance if prescribed by the doctor.

6. Organ Donor Expenses

   Most health insurance plans also cover the medical expenses incurred on the surgery performed to harvest an organ from a donor for the transplant surgery.

7. Maternity and Newborn Baby Cover

   In today's times, most health insurance companies offer maternity insurance that covers medical expenses incurred during pregnancy and childbirth. This type of insurance not only covers the cost of delivery, hospitalization, pre-natal care, post-natal care, diagnostic tests, etc., but also newborn baby's treatment and vaccination expenses.

8. AYUSH Treatments

   Several mediclaim policies also cover medical expenses incurred on healthcare treatments availed through Ayurveda, Unani, Siddha, Yoga or Homoeopathy systems of medicine.

Note: The above medical expenses list is not exhaustive. Please read your policy wordings for a detailed list of covered medical expenses.

Which Medical Expenses are Not Covered in Health Insurance?

Even though the list of exclusions varies as per the plan, the following are some of the common medical expenses that are generally not covered under a health insurance:

• Self-inflicted Injuries: Health insurance does not cover self-harm or suicide attempts.
• Cosmetic or Plastic Surgery: Unless medically necessary due to an accident or illness, cosmetic procedures and plastic surgeries are not covered.
• Hormone Replacement Therapies: Cost of hormone replacement therapies are excluded.
• Treatment for Alcoholism, Drug or Substance Abuse: Medical expenses related to alcoholism, drug, or any addictive substances are not covered.
• Sterility Treatments: Expenses incurred on any type of contraception or sterilization are excluded.
• Cosmetic or Plastic Surgery: Cost of cosmetic or plastic surgeries, unless medically necessary, are not covered.
• Dietary Supplements: Expenses incurred on purchasing any dietary supplement or substance that can be bought without a doctor's prescription are not covered.

Note: The above list of exclusions is not exhaustive. Please read your policy wordings for a detailed list of exclusions.

Why is it Important to Understand Medical Expenses Covered in Health Insurance?

It is important to understand what exactly is considered medical expenses in health insurance for the following reasons:

• Choosing the right health insurance plan
• Planning for medical emergencies
• Avoiding claim rejections
• Reducing out-of-pocket expenses
• Accurately filing claims and saving time