Non-Active Treatment during Hospitalization
Under this clause, expenses incurred on hospitalization purely for diagnostic or investigation purposes without any active treatment during the course of hospitalization are not reimbursable by Insurance.
Treatment that does not justify hospitalization or extended stay in hospital without ample justification is liable to attract rejection of the claim. Under this clause, treatment can be taken at home and the presenting symptoms may not necessitate immediate hospitalization.
Admission of an aged person in the hospital for medical check-up, treatment and rest also falls under this category and fails to qualify for reimbursement.
Hospitalization wherein no active treatment has been administered to the patient does not qualify for reimbursement procedure. There are instances wherein a patient gets hospitalized on account of some minor ailment such as mild fever (100 degrees or less temperature) with 1 or 2 episodes of vomiting that do not justify hospitalization and during the hospitalization period only 2-3 vials of injections may be administered (just for show), are also likely to be rejected. Other instances include hospitalization for abdominal pain, flatulence, false labor pains etc. But this depends on individual case-to-case study for taking an appropriate medical decision by the competent authority. This is quite common with corporate employees who try to manipulate this clause in order to make a quick buck, not only for themselves, but also for their family members by getting the necessary reimbursement from Insurance companies. Insurance companies have already made a serious note of this moral hazard which is being knowingly carried out to derive benefits out of health policy cover provided by their employers which has resulted in severe bleeding of the Insurance sector. This in turn has resulted in fiscal bleeding of the Indian economy and a tab on such cases is being kept by Insurance companies. Plans are being prepared to take action against erring policyholders for their personal benefits or quick gains.
Hospitalization for the sake of investigation that has no co-relation with the presenting signs and symptoms in an individual is likely to attract repudiation of the claim.