What is the Pre-Post Hospitalization in Health Insurance?

We often hear that health insurance generally does not cover the cost of OPD, which is true. To cover the cost of special OPD, health insurance provides a separate option to cover you as a rider up to a limit. It is perfect to hear that now there is no need to be admitted for 24 hours, an OPD claim will also be received without being admitted to the hospital.

Wait, sir/madam, now let’s understand that the Insurance business depends on pool size and probability. Now the likelihood of hospitalization within 24 hours is much less than the probability of OPD so the health insurance company will charge extra for OPD coverage.

Almost all OPD reimbursement claims are available for those hospitalised for 24 hours or more.

One point that needs to be taken care of is that we are admitted to the hospital for the treatment of OPD-related treatment/disease and that is the reason why we get reimbursement for that OPD also and then we have to pay for OPD optional cover from the beginning. Then what is the benefit?

Now the question arises of which OPD expenses are covered in Pre-Post, let us understand it with an example. Mr. Goptal is an insured person, he has a fever and he went to a general physician (MBBS and Above) for OPD and he was prescribed medicine for 2 days. The doctor said that after 2 days he would have to come for a follow-up checkup. after 2 days, but his fever was not cured, in this situation, the doctor recommended a pathology test called “Fever Panel” and after reading the report of the pathology test came to know that Mr Gopal had dengue and platelet count was very low, then OPD treating doctor asked him to be admitted to the hospital, now this will be called IPD hospitalization and admission is justified, now as per the plan Mr Gopal Doctor will file reimbursement claim for Consultation Fee, Pathology expenses, Medicine expenses, it varies from plan to plan and insurance company to the insurance company as to how many days the pre-hospitalisation expenses will be, it can be for 30, 60, or even 90 days.

Point to remember while claiming reimbursement Claim

• Pre-Hopitalisation Treatment Expenses Accepted when the Hospitalisation will be done for the same treatment.
• Pre- Hospitalisation will be accepted when it is when claims we have made expenses beyond pre-hospitalisation days, i.e. admitted in hospital on 31st Dec and if there are 30 days of pre-hospitalisation till 1st December, related OPD expenses
• Pre-post Hospitalisation expense claims should be accepted for the related OPD Treatment in which the insured person was hospitalised
• Pre-Post Hospitalisation Expenses Claim will be filled on a reimbursement basis only, no cashless facility is available for the same.
• Post Hospitalisation, will be counted during the policy period, whether the policy expired or in the grace period, e.g Suppose, an insured person’s policy expires on 31st Dec and his IPD Claim comes on 25th Dec, and his Post Hospitalization is for 180 days, why has his policy been ported or not renewed even after 25th? Dec will be eligible for post-hospitalization expenses of IPD if the sum insured is available.
• Nowadays Insurance Companies will be asked for justification for late submission of these claims, generally after 30 days, so file a claim as early as possible

Conclusion: For every pre-post OPD related only to the main Hospitalization (e.g. IPD Hospitalisation for given treatment only.

About the writer – Kumar has more than 2 decades of personal finance Sales, Operations, Health Insurance Underwriting, and Health Insurance Claims, and has been associated with multiple training teams for Learning and Development.