Domiciliary Hospitalization in Health Insurance and Claim | Pazcare

What is domiciliary hospitalization?

Domiciliary hospitalization meaning a case where a patient has an illness or disease that requires hospitalization but gets it from home because of the below reasons:

1. The medical condition is such that the patient cannot be moved to the hospital and it is best to treat immediately from home or is having a prolonged treatment for recovery.
2. The hospital chosen doesn’t have the required facilities to treat the patient (lack of beds, equipment, etc.)

In recent years, domiciliary care has gained importance due to hospital bed shortages and the rising preference for home-based care among patients with chronic or infectious conditions. According to a 2023 Niti Aayog report, over 18% of patients with chronic conditions in urban areas opted for home care services over hospital admission.

Domiciliary hospitalization in group health insurance

There are two types:

1. Domiciliary hospitalization is included by default in a few insurance policies.
2. Domiciliary hospitalization is bought as a rider to the base plan

Rider in insurance means an extra or add-on cover bought over the base plan with an additional premium.

Who gives domiciliary hospitalization by default?

Here are a few insurers who give domiciliary hospitalization by default in some of their covers.

1. Edelweiss general Insurance
2. Tata AIG

However, it is important to check with your insurer if domiciliary hospitalization is included or excluded.

When Should Employers Consider Offering Domiciliary Hospitalization?

• During pandemics or seasonal outbreaks with hospital shortages
• For employees in Tier 2 or Tier 3 cities where hospital infrastructure is limited
• When offering hybrid or remote-first healthcare benefits to reduce physical hospital visits

‍What is Covered Under Domiciliary Hospitalization?

Domiciliary hospitalization covers medical treatment at home that would otherwise require hospital admission. Most insurers cover:

• Medical treatment at home (as per doctor’s written advice)
• Illness or injury requiring active monitoring by a certified medical practitioner
• Doctor home visits or teleconsultation (in some modern plans)
• Prescribed medicines and injections administered at home
• Home nursing or health aide costs (if included in the plan)

What is Not Covered Under Domiciliary Hospitalization?

Domiciliary hospitalization does not cover the following:

• Pre & post-hospitalization expenses
• Home treatment taken for less than 72 hours
• Treatment not recommended by an MBBS doctor

Also, The following diseases cannot be claimed under domiciliary hospitalization according to IRDA.

1. Asthma
2. Bronchitis;
3. Chronic Nephritis and Nephrotic Syndrome;
4. Diarrhea and all types of Dysenteries including Gatro-enterities;
5. Diabetes Mellitus Insipidus;
6. Epilepsy;
7. Hypertension;
8. Influenza, Cough and cold;
9. All Psychiatric or Psychosomatic Disorders;
10. Pyrexia of unknown origin for less than 10 days;
11. Tonsillitis and Upper Respiratory Tract Infection including Laryngitis and Pharyngitis
12. Arthritis, Gout and Rheumatism

Read: ICU Room and Hospital Room Rent Limit In Health Insurance

How to Claim Domiciliary Hospitalization in Group Health Insurance?

The process generally includes the following steps:

1. Doctor’s Certification: Get a written note from a certified doctor stating that hospitalization is required but cannot happen due to condition or bed shortage.
2. Collect All Medical Records: Maintain prescriptions, medicine bills, test reports, and nurse/doctor visit logs.
3. Get Employer-Provided TPA Details: Use your company’s TPA (Third Party Administrator) or Broker/insurer’s portal.
4. Submit Claim with Documents:
   
   • Doctor’s advice letter
   • Diagnosis & treatment details
   • Pharmacy & medical bills
   • Hospital bed unavailability certificate (if applicable)
5. TPA Verification: Your TPA will process the claim. Some insurers may allow pre-authorization or require approval before treatment starts.
   

How does claim for domiciliary hospitalization work?

Here are some pointers that will help you understand the claim process under domiciliary hospitalization.

• Pre and post-hospitalization expenses are not covered in domiciliary hospitalization
• Treatment exceeds more than 3 days and generally requires a doctor to treat.
• Domiciliary hospitalization comes with a waiting period that differs with different insurers. You can file a claim when the waiting period is over. However, if you have group health insurance (insurance given by your employer) you may not have a waiting period.
• Check with your insurer on the cap of the domiciliary hospitalization. For example, if you have a group health insurance cover of 3 lakhs and a cap on domiciliary hospitalization is 10%, then you can claim 30,000 for domiciliary hospitalization expenses.
• To claim you need to have the bills and the treating doctor’s letter to the insurance company (TPA), stating the reason for domiciliary hospitalization.

Digitally managing home hospitalization documentation through your Broker's app or dashboard can streamline the claims and improve approval turnaround time.

Read: How to calculate health insurance premium?

Domiciliary hospitalization and COVID-19

COVID-19 is one such disease that sometimes requires domiciliary hospitalization and is specifically categorized as Home Quarantine. Here’s what Insurance Regulatory and Development Authority (IRDA) tells about domiciliary hospitalization for COVID-19.

• You need confirmation of COVID-19 by any lab recognized tests by ICMR.
• Any Medical Expenses payable shall not in aggregate exceed 50% of the annual sum insured.
• The domiciliary hospitalization happens for not more than 14 days.
• Needs to be medically necessary and must be on the written advice of a doctor followed by observation chart and medicine bills

In general,  the expenses for domiciliary hospitalization for COVID-19  is capped at a maximum of INR 15,000 for the PSU insurers.

Offer employee healthcare benefits with Pazcare

If you are looking for a group health insurance policy for your team with domiciliary hospitalization, you have come to the right place! Along with GHI we provide your team with other benefits like

• Group term life coverage
• Corporate wellness programs
• Group personal accident cover

With the onset of novel coronavirus pandemic, we also provide covid insurance policy for the employees.

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