Inpatient, day-patient and outpatient cover, explained

IPMIAfrica explains the three building blocks of international private medical insurance, inpatient, day-patient and outpatient, what each pays for, how the modules fit together and how to decide which ones an expat in Africa actually needs.

The three building blocks

Almost every international health insurance plan is built from the same three blocks, and the names refer to where and how treatment happens rather than to what is wrong with you.

• Inpatient treatment is care that needs you to be admitted to a hospital bed, usually overnight or longer. Surgery, intensive care, cancer treatment in hospital, serious infections and childbirth in hospital are inpatient.
• Day-patient treatment is care that needs a hospital bed or theatre but not an overnight stay. You are admitted, treated and discharged the same day. Minor surgery, endoscopy, some chemotherapy sessions and some diagnostic procedures are day-patient.
• Outpatient treatment is everything that does not need a bed: consultations with a GP or specialist, blood tests, scans, physiotherapy, prescriptions and vaccinations.

Inpatient is the core of every plan and is always included. Day-patient is almost always grouped with inpatient. Outpatient is the module you choose to add or leave out, and it is where most of the decisions, and most of the cost differences, sit.

What inpatient and day-patient cover pays for

The inpatient benefit is designed for the large, expensive, infrequent events. A typical inpatient and day-patient benefit covers:

• Hospital accommodation, usually a private or semi-private room, and nursing.
• Surgeons', anaesthetists' and physicians' fees for treatment while admitted.
• Operating theatre, intensive care and high-dependency care.
• Diagnostic tests, scans and drugs while you are admitted.
• Cancer treatment, including chemotherapy and radiotherapy, though some plans cover these as inpatient regardless of where they are given and others treat them separately.
• Emergency treatment that leads to admission.
• Evacuation and repatriation, on most plans, as part of or alongside the inpatient benefit.

Three things to check. First, the annual limit, which is the most the plan pays in a year across all benefits. Second, any sub-limits inside it, for example on cancer, organ transplant or rehabilitation. Third, how the plan treats the care around an admission: pre-admission tests and post-discharge follow-up are sometimes covered under inpatient for a set period, and sometimes fall into outpatient.

What outpatient cover pays for

Outpatient cover pays for the care you use most often. A typical outpatient module covers:

• GP and specialist consultations.
• Diagnostic tests, blood work, X-rays and scans ordered as an outpatient.
• Prescribed medication.
• Physiotherapy and other therapies, often with a session limit.
• Vaccinations and health checks on some tiers.
• Mental health consultations on some tiers.

Outpatient modules are usually sold with an annual cap, and some plans add a separate excess or co-insurance to outpatient claims only. A lower cap or a higher outpatient excess brings the price down. Some plans also cover chronic condition management, which is the regular monitoring and medication for a long-term condition, under outpatient; others exclude it or limit it, which matters a great deal if you have one.

Outpatient is also where the direct billing question most often bites. Hospital admissions are usually settled between the hospital and the insurer; outpatient visits in much of Africa are paid in cash and reclaimed. Ask how the insurer handles outpatient claims and how long reimbursement takes.

How plans are built in tiers

Most insurers sell three or four tiers. The names vary, but the structure is consistent.

Each step up the tiers adds benefits and cost. The tiers are not better or worse in themselves; they are suited to different ways of using the plan. The IPMIAfrica insurer pages describe how each insurer's tiers are structured, and our comparisons such as Cigna vs IMG put two side by side.

Deciding what you need

The honest way to choose is to think about how you will use the plan over a year, not about which tier sounds safest.

• How often do you see a doctor? If the answer is rarely, outpatient cover may cost more than you would spend paying as you go. If it is several times a year, or you have children, outpatient usually pays for itself and removes the temptation to put off a visit.
• Do you take regular medication? If so, you need an outpatient module that covers chronic condition management, and you need to understand how your condition will be underwritten. See our pre-existing conditions guide.
• Where do you live? In a city with good private clinics, outpatient care is accessible and relatively predictable. On a remote site, the question is less about outpatient cover and more about evacuation.
• Who is covered? Children generate outpatient claims. Families usually find a comprehensive tier better value than inpatient only.
• Could you absorb an excess? A plan with outpatient and a sensible excess often costs about the same as a plan without outpatient and no excess, and covers far more.

Common pitfalls

• Assuming cancer is always inpatient. Much modern cancer treatment is given as a day-patient or outpatient. Check whether the plan covers it in full regardless of setting.
• Missing the outpatient cap. A low cap can be exhausted by one serious diagnostic work-up. Compare caps, not only whether outpatient is included.
• Confusing a visit to A&E with admission. Emergency treatment that does not lead to admission is usually outpatient. Some plans cover emergency outpatient treatment even on inpatient-only tiers; others do not.
• Forgetting pre- and post-admission care. Tests before surgery and follow-up after discharge may be inpatient for a set period, then outpatient. Check the wording.
• Treating evacuation as separate. It is usually part of the inpatient benefit or sits alongside it. In Africa, do not buy a tier without it. Our evacuation guide explains why.

How to compare the modules

When you compare plans, line up the same six things for each: the annual limit, whether day-patient and cancer are covered in full, whether outpatient is included and the cap on it, whether chronic condition management is inside outpatient, how pre- and post-admission care is treated, and whether evacuation is included. Then compare price. A plan that looks cheaper is often cheaper because one of those six is missing. Nomi asks the questions that pin these down and then quotes 20+ insurers for the same brief.

Frequently asked questions

This page is general information, not personal or medical advice. Prices are indicative and confirmed by the insurer at underwriting. For advice on your situation, speak to an experienced broker.