Minimum Number of Beds and Exceptions
a) Has been registered as a Hospital or Nursing Home with the local authorities and is under the supervision of a registered and qualified Medical Practitioner
b) Should comply with minimum criteria as under:-
i) It should have at least 15 in-patient beds.
ii) Fully functional operation theatre of its own, where surgical operations are carried out.
iii) Fully qualified Nursing Staff under its employment, round the clock.
iv) Fully qualified Doctor(s) should be in-charge, round the clock.
N.B.: In class “C” towns, the condition of number of beds is reduced to 10.
a) Remember, if you wish to be sure that your claim goes through the first thing is to ensure that the hospital has the minimum beds as required by your policy and it is a registered hospital or nursing home, otherwise it would be rejected. Your check list should therefore include the following - Hospital/Nursing Home should be registered under the category of “Hospital” with a local body that includes municipal corporations, municipalities, village panchayats etc.
b) It should possess IPD (In-Patient Department) facilities for qualifying as a Hospital.
c) Care and active treatment of the sick, diseased and injured patients only, is applicable under this clause.
d) Minimum 15 beds or more are essential in an IPD ward apart from the patients examination table, trolleys, stretchers etc. all under one roof.
There are many Eye and ENT Hospitals that do not fulfill the criteria pertaining to 15 beds, but do have the requisite health care facilities for IPD care along with Operation Theatre facilities. Though, in India, Eye hospitals have less than 15 beds or 2-3 beds only, claims are still applicable for both-Cashless and Medical Reimbursement facilities. Examples of treatment include Cataract surgery, Glaucoma treatment etc.
However if the hospital is not registered (or in the process of registration) and the beds in a hospital are below the permissible limits as specified as per IRDA Act, it may lead to disqualification of the claim.
There are numerous instances too wherein the hospital has 15 or more beds with the all the desired healthcare facilities for the treatment of patients, but the hospital is not registered with the local body. The medical treatments availed at such hospitals can be claimed for medical re-imbursements subject to certain policy conditions issued by Non-Life (General) Insurance companies. There are certain states in India where the regulatory mechanism for registration of hospitals is a slow process. In such situations the insurance company has no option but to overlook this fact for the benefit of the public. But this is not acceptable in Indian states like Maharashtra, Gujarat, Tamil Nadu, Kerala, Andhra Pradesh, and Karnataka where the infrastructure is adequate and the regulatory mechanisms are enforced fairly well.
Based on the guidelines issued by IRDA, 15 numbers of beds are a pre-requisite for any hospital in urban and semi-urban areas. Some policyholders with malafide intentions try to derive undue advantage from health insurance policy cover and apply for reimbursement which attracts repudiation of the claim. In this context there are instances of some medical clinics, Physiotherapy and Ayurvedic/Siddha clinics wherein treatment is administered for 7, 14, 21 or 35 days on OPD basis, based on the nature of the presenting symptoms. At the end of the treatment Discharge Summary, Pharmacy bills and Physicians prescriptions are issued for making a claim.
Treatments availed at medical centers that have a license as a commercial establishment (may possess commercial registration under Establishment Act) are not eligible for medical reimbursement or cashless facility.