Medical insurance policies don’t cover all expenses incurred on hospital treatment. Becoming aware of the exceptions will help in the selection of a medical policy and reduce one’s out-of-pocket expenses.

A regular health insurance policy covers all medically necessary treatment expenses by default. However, there are certain non-medical expenses outlined by the regulatory authority that the policyholder may have to pay for unless explicitly included in the plan’s policy or customer information sheet. It is important to understand such expenses to avoid surprises while settling claims.

The key advantage of health insuranceis experienced during a medical emergency. It prevents the financial strain of paying hefty hospital bills out-of-pocket for the treatment of listed medical conditions. However, it is incorrect to assume that the insurance company will cover all expenses by default.

ospitalisation costs comprise a wide range of items that are categorised into medical and non-medical expenses. The cost of each non-medical expense, as stipulated by the Insurance Regulatory and Development Authority of India (IRDAI),  may be negligible. But the cumulative amount of all such expenses, which are typically excluded from coverage unless otherwise specified, could be quite substantial, especially in the case of prolonged hospitalisation. It is crucial to be aware of such exclusions to avoid surprise deductions from claims submitted to the insurer.

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The regulatory authority, in a circular dated September 27, 2019, defined four broad categories along with a specified list of non-medical items that do not necessarily get covered by all health insurance policies. Instead, insurers can treat them as “optional” or they should be “subsumed” in other charges to be considered for payment by the insurance company.

Optional items

These are non-medical items that are not mandatorily covered. They may or may not be paid for by the insurer at their discretion.

Examples of such optional item charges are: food (other than hospital-provided food as advised to the patient), beauty services, laundry, gloves, private nurse/special nursing, guest services, walking aids, and documentation-related expenses (photocopy and courier).

Costs that are part of room charges

This is a category of non-medical expenses that should come under hospital room-related expenses. They are not to be billed separately (in which case the insurer is not liable to pay for them). Instead, they are deemed as included in the overall room charges.

Examples of non-medical expenses related to room charges are: toothpaste, toothbrush, handwash, tissue paper, gown, slippers, shoe cover, foot cover, disinfectant lotions, clean sheet, blanket, housekeeping, documentation, and administrative expenses.

Expenses subsumed into procedure charges

These refer to expenses that are a part of the surgical or other invasive medical procedures. Here, too, the expenses are deemed as included in the overall charges and should not be billed separately.

Examples of non-medical expenses related to procedure charges are: eye pad, eye shield, eye kit, eye drape, surgical tape, cotton, gauze, surgical instruments, surgical blades, ward and theatre bookings, DVDs and CDs, arthroscopy and endoscopy instruments, and X-ray film.

Expenses that form part of treatment costs

Some non-medical expenses are part of the medical treatment and should not be billed separately. For instance, admission/registration, hospitalisation for diagnoses, nutrition planning, dietitian, blood reservation, antiseptic mouthwash, mouth paint, vaccination, glucometer & strips, and urine container. A detailed list of all non-medical expenses can be found on the IRDAI website.

Be prepared to pay for non-medical expenses

Health insurance does not always cover every single expense incurred while undergoing treatment at a medical facility. All health insurance policies are subject to terms and conditions as listed in the policy or customer information sheets issued by the insurance company.

It is advisable to read the details and gain a thorough understanding before choosing a plan for you and your family members for a lifetime and to mitigate any future issues related to medical claims.

It also acts as a guide to correct billing and invoicing from a hospital where treatment has been sought.