A Mediclaim policy provides the policyholder with financial assistance through cashless facilities or reimbursement during medical treatments and hospitalisation. It covers the insured against any medical expense that might occur during the policy period and also offers tax benefits under section 80D of the Income Tax Act of India, 1961.
What is Mediclaim?
A Mediclaim is a form of insurance wherein the insurance providers reimburse the policyholder for any medical expenses that he/she might have incurred in the policy period. The insured can either submit the relevant bills to get reimbursed or avail completely cashless facilities at the insurer's network hospitals.
Skyrocketing medical inflation rates have made Mediclaim policies or health plans a necessity to make healthcare affordable for the larger masses. Mediclaim policy is a type of health insurance that offers a health cover for illnesses and hospitalisation up to a specific sum insured. Such policies are valid for a particular period after which the policyholder has to renew it to enjoy the benefits.Mentioned below are some important aspects of a Mediclaim policy:
- Premiums: The premiums paid for Mediclaim policies differ from one insurer to another however, the factors that influence the amount are constant. Age, sum insured, policy period, etc., are a few of the factors that affect the premium.
- Age: Mediclaim policies can be bought only if the consumer falls in the specified age group. Usually, insurers have an entry age of 18 years and an exit age of 65 years. However, sometimes the age group can start at 5 years and go up to 80 years.
- Family cover: In a family cover, the policyholder can pay a master premium to cover his/her entire family instead of buying individual policies.
- Overseas Mediclaim policies: Many insurers provide overseas Mediclaim policies under which the insurer can seek treatment in both India and abroad. However, such policies have certain conditions attached to them.
- Claims: Claims are usually made through third-party administrators (TPA), but some insurers deal with claims in-house.
- Types: Mediclaim policies cater to different needs and different individuals. One can choose from individual policies, group policies, critical illness policies, senior citizen policies, and maternity policies.
- Tax benefits: Under section 80D of the Income Tax Act of India, 1961, policyholders can claim a tax deduction of Rs.25,000 against the premium paid for Mediclaim policies. The exemption limit is Rs.30,000 for senior citizens. Policyholders can claim an additional exemption of Rs.25,000 if they are paying the policy premiums for their parents.
Difference Between Mediclaim Policies and Health Insurance
The terms health insurance and Mediclaim policy are often used synonymously, however, both of them are different in nature. A Mediclaim policy works on an indemnity basis which means that any medical expense incurred by the policyholder will be reimbursed by the insurers. On the other hand, health insurance plans function on the benefit principle where a certain lump sum is paid out if the policyholder meets with a certain eventuality like critical illness, accident, etc.
Listed below are some of the major distinctions between a Mediclaim policy and health insurance:
|Feature||Mediclaim policy||Health insurance|
|Coverage||Mediclaim policies cover medical expenses and hospitalisation charges.||Health insurance covers hospitalisation charges along with additional expenses like ambulance charges, daily cash allowance, etc.|
|Claim||Policyholders can make unlimited claims until the sum insured is exhausted.||Policyholders are given a lump-sum amount if they meet with an accident or are diagnosed with a critical illness. The cover ceases to exist after the pay-out.|
|Sum insured||Mediclaim policies usually have a lower sum insured.||Comprehensive health insurance plans offer a higher sum insured that can go up to a crore at times.|
Types of Mediclaim Policies Available in India:
The following types of Mediclaim policies are available in India for consumers to choose from:
- Individual Mediclaim: An individual Mediclaim policy covers the policyholder alone against any medical expenses.
- Family floater: In a family floater Mediclaim plan, a master premium is paid that financially supports the family members against any medical liabilities.
- Group Mediclaim: In group Mediclaim policies, an employer or a person-in-charge of a group buys the policy for the employees/members. It is usually an addition to the compensation provided by the employer.
- Senior citizen Mediclaim: Such policies are specifically designed for senior citizens and often have special provisions or require testing.
- Critical illness Mediclaim: Mediclaim policies cover the medical expenses pertaining to the treatment of critical illnesses like cancer, kidney failure, multiple sclerosis, etc.
- Overseas Mediclaim: An overseas Mediclaim policy allows the insured to make claims for medical expenses that were incurred outside India.
- Low-cost Mediclaim: Low-cost Mediclaim policies are targeted at the underprivileged section of the society. Such policies are usually bought by employers in small and medium scale industries to insure their employees at low premiums.
Inclusions in Mediclaim Policies
A good Mediclaim policy can protect the insured against a vast range of medical expenses. Some of the expenses covered under such plans are mentioned below:
- Hospital charges: It includes all the expenses incurred during the policyholder's hospital stay. Such expenses usually consist of medicines, blood, oxygen, operation theatre charges, organ donor expenses, x-rays etc.
- Day-care treatment: It consists of the expenses pertaining to advanced medical treatments that do not require the patient to stay in the hospital for 24 hours.
- Pre and post-hospitalization charges: Mediclaim policies usually cover the expenses incurred during the period before and after hospitalization. The covered period varies between insurers and can range from 30 days to 90 days. Such expenses usually include doctor's consultation fees, lab tests, and follow-up check-ups.
- Hospital stay: Hospital room rent can get very expensive at times. However, Mediclaim policies cover the room rent as well. Rent for wards, private rooms, or ICU is fully reimbursed by the insurers or availed through cashless facility.
- Medical professional's fee: Certain Mediclaim policies also cover the costs of consultation fees and medical professional's fees such as doctor's fees, nurse's fees, etc.
Exclusions of Mediclaim Policies
Exclusions refer to the diseases and medical conditions that are not covered under the policy. When buying a policy, the first 30 days are treated as the waiting period where claims can't be made. If the policyholder gets diagnosed with any disease in that duration, it won't be covered by the insurer.
The exclusions differ from one insurer to another. However, here are some medical conditions that are usually excluded from the policy:
- Pre-existing diseases
- Sexually transmitted diseases (Including HIV/AIDs)
- Pregnancy and childbirth
- Dental treatments
- Cosmetic surgery and obesity-related treatments
- Plastic surgery
- Hearing aid, contact lenses, etc.
Benefits of a Mediclaim policy
Mentioned below are some notable benefits of a Mediclaim policy:
- Cost-effective: It is an affordable way to combat rising healthcare costs.
- Medical emergencies: Investing in a Mediclaim policy can prevent any financial stress during medical emergencies like accidents.
- Cashless claims: It offers cashless facilities where the policyholder doesn't have to shell out any money from his/her pocket during hospitalization. The insurer pays the hospital directly.
- Tax benefits: Investing in a Mediclaim policy allows the policyholder to claim tax benefits under section 80D of the Income Tax Act of India, 1961.
Claim Process for Mediclaim Policies
Mediclaim policies give policyholders the option of cashless facilities and reimbursement claims. In cashless facilities, the insured can get treated in any of the network hospitals of the insurance provider without paying anything from his/her pocket. However, if the policyholder chooses a hospital which is not in the insurer’s network, he/she has to bear the expenses which will be reimbursed by the insurer upon filing a claim.
Mentioned below is the process for filing claims:
- Reimbursement claims: When going for reimbursement claims, it is imperative to inform the insurers or the TPA as soon as the policyholder gets hospitalized. It is important to keep all the bills and a track of expenses incurred during hospitalization. When filling the claim form, the bills have to be attached and the details are required to be filled in correctly. Even a minute error can delay the reimbursement process.
- Cashless claims: The policyholder is expected to sign a 'preauthorization form' advance for planned cashless hospitalization. In case of emergency treatments, the insured can show his/her Medi-Assist ID card issued by the insurance provider at the network hospital after which the policyholder will be given 4 hours to fill the preauthorization form.
Factors to Remember When Buying a Mediclaim Policy
Buying a Mediclaim policy seems like a necessity with healthcare costs on a constant rise. However, it is essential to invest in a policy that suits the consumer’s needs. The following factors should be considered when buying a Mediclaim policy:
- Coverage: Selecting an adequate sum insured is essential to ensure a good coverage. A higher sum insured might result in a higher premium amount but assessing one’s needs and picking the coverage can go a long way in protecting oneself against medical expenses.
- Co-payment: Under a co-payment clause, the insured is expected to pay a specific percentage of the claims. A policy with a co-pay feature is usually much cheaper.
- Sub-limits: Before buying a policy, it is crucial to take a closer look at the sub-limits as certain insurers have specific limits on some illnesses and treatments.
- Waiting period: Claims can’t be made during the waiting period except for hospitalization due to accidents. Additionally, insurers have a waiting period for pre-existing illness and other diseases as well. Checking the exclusions during the waiting period can help the consumer make a better decision.
- Network hospitals: Cashless facilities can only be availed in the network hospitals of the insurance provider. Therefore, a vast network of hospitals ensures that the policyholder has various options across different geographical locations.
- Add-ons: Generally, Mediclaim policies do not offer add-on riders. But if the insurer provides it, investing in add-ons can significantly enhance the policy. However, buying unnecessary add-ons will only increase the premium amount without being useful for the policyholder.
- Exclusions: Being aware of the exclusions in the policy is important as ignorance might lead to confusions when filing for a claim.
- Free look period: A free look period allows the policyholder to return the policy and get a refund if he/she is not happy with the plan. This period gives the insured adequate time to go through the policy details. Using this time wisely can prevent the consumer from falling into a bad deal.
Mediclaim Policy FAQs:
ANS: Health insurance portability allows a mediclaim policy to be ported from the existing insurer to another insurer at the time of renewal without losing benefits such as waiting period and no-claim bonus. Portability is advisable if no claims have been made and the insurance premium is high or the claim process is challenging with the existing insurer. Only similar policies can be ported. Mediclaim policy can be ported with same insurer. The portability request has to be submitted 45 days prior to the policy expiry date.
ANS: Visit a third-party comparison website like BankBazaar.com to compare various mediclaim policies across the top insurance providers. Choose one that offers sufficient coverage at an affordable premium. Go to the chosen insurer's official website and apply for the policy, premium payment can be made online through the website using net banking, credit card or debit card.
ANS: Visit the National Insurance website and click on ‘Renew Existing Policy’. It will redirect you to a page where you can renew the policy by entering the policy number and registered email ID. You can view the renewal notice and total renewal premium to be paid. You will be directed to a secure payment gateway where you can make premium payment using net banking, credit card or debit card.
ANS: Before purchasing a mediclaim policy, determine whether you require an individual policy or a floater plan for your family, the renewability age criteria given by the insurance company, and if the chosen policy will cover pre-existing diseases. In order to select the right policy, compare the features and benefits of various mediclaim policies on an online comparison website like BankBazaar.com.
ANS: Most insurance providers have an online insurance premium calculator on their websites. All you have to do is enter few personal details, the number of insured members, chosen sum insured, and the age of the eldest member in the online premium calculator. Click on ‘Proceed’ and the tool will display the insurance premium of your policy
ANS: Mediclaim policy will cover all your medical expenses in the case of hospitalisation or domiciliary care during the policy term. With the rise in healthcare costs and lifestyle diseases, having a mediclaim policy is useful. You don’t have to pay for the medical expenses out of your pocket. With a mediclaim policy, you and your family can get timely and adequate healthcare.
ANS: Employers in India offer a group health insurance policy to their employees as an incentive to retain talent in the company. Government employees receive health cover via central and state government insurance-based schemes. Employees can include their family members in the health cover. Mediclaim policy also gives tax benefits to the assessee on premiums paid towards a health insurance policy under Section 80D of the Income Tax Act, 1961.
ANS: In the case of a cashless mediclaim policy, all medical expenses are paid by the insurance company directly to the network hospital where the treatment is received. Cashless claim is subjected to the sum insured limit. The insured member doesn’t have to pay the medical expenses out of his or her pocket. Mediclaim cashless facility can be availed only in a network hospital of the insurer.
ANS: A group mediclaim policy covers the all employees of an organisation and their beneficiaries in the case of a hospitalisation or domiciliary care during the policy term.
ANS: In the case of a floater mediclaim policy, the sum insured can be shared by any or all members of the family for any number of claims during the policy term subject to the specified sum insured limit. A family floater mediclaim policy covers all the members of your family which includes self, spouse, children, and parents under one plan.
ANS: Overseas mediclaim policy covers medical expenses incurred due to an accident or sudden illness when traveling overseas. Your regular health insurance policy may not cover medical expenses incurred on a foreign soil. The healthcare costs in foreign countries are exorbitant, having an overseas mediclaim policy can be beneficial.
ANS: Health cover is a dynamic concept which keeps changing with time and the varying needs of the customers. Innovations in health insurance over the years are as follows:
- Health insurance portability: Your mediclaim policy can transfered from one insurer to another without losing out on the policy benefits such as waiting period and no-claim bonus at the time of policy renewal.
- Family floater plan: One policy will cover all the members of your family including self, spouse, children, and parents.
- Add-ons or riders: Critical illness cover, personal accident insurance cover, hospital cash benefit, and maternity benefit cover are some of the riders that can be attached to your base health insurance policy for an enhanced health cover.
- Lifelong renewability: Choose plans with a lifelong renewability option so that you can get health cover when you need it the most. Nowadays, most health insurance policies come with a lifelong renewability option.
- Top-up health insurance plans: You can opt for a top-up health plan with a health cover of Rs.7-8 lakh and attach it to your base policy health cover of Rs.2-3 lakh to get a higher sum insured at a cost-effective rate.
- Conditional cover replenishment: If no claims have been made, the health cover will be doubled for the following year at no extra cost.
- Unit-Linked Health Insurance plans: These mediclaim policies offer health cover combined with investment. However, the returns will be affected a claim is made.
ANS: An individual mediclaim policy covers only one person in the case of hospitalisation or domiciliary care due to sudden illness or accident during the policy term.
ANS: National mediclaim policy covers hospitalisation expenses incurred for treatment of illness or injury of the insured member during the policy term. Individuals between 18 to 65 years of age are eligible for this policy. You can get coverage for children between the ages of 3 months to 18 years along with a parent. Over 140 day-care procedures are covered. You can avail cashless facility, tax benefits, and family discounts.
ANS: Listed below are some of the top mediclaim policies for parents in India:
- Red Carpet Health Insurance Policy by Star Health and Allied Insurance for senior citizens aged between 60 to 75 years.
- Silver plan Health Insurance Policy by Bajaj Allianz for senior citizens till 75 years of age.
- Easy Health Insurance Policy by Apollo Munich for senior citizens till 65 years of age.
- Heatbeat Health Insurance Policy by Max Bupa for senior citizens with no age restriction.
- Rishtey Health Insurance Policy by ICICI Lombard General Insurance for senior citizens till 70 years of age.
ANS: Most insurers offer cover for pre-existing diseases after a 4-year waiting period. Group health insurance plans cover pre-existing diseases from day one.
- Red Carpet Health Insurance Policy for senior citizens from Star Health and Allied Insurance covers pre-existing diseases from first year.
- Silver Health by Bajaj Allianz covers pre-existing diseases from second year.
- SBI Life Smart Health Insurance covers pre-existing diseases after completion of 2 years.
- ICICI Lombard Complete Health Insurance with a coverage of Rs.3 lakh or more will cover pre-existing diseases after 2 years.
ANS: Listed below are some of the top mediclaim cashless policies available in India:
- Easy Health Standard by Apollo Munich
- Bajaj Health Guard by Bajaj Allianz
- Mediclassic by Star Health and Allied Insurance
- Health Companion by Max Bupa
- Health Care Supreme by Bajaj Allianz
- Optima Restore by Apollo Munich
ANS: Cosmetic procedures like LASIK surgery are usually not covered under regular health insurance policies.
ANS: Dental treatments are usually not covered by health insurance plans in India. However, special dental cover plans can be attached to the base policy to get dental cover. Here are a list of health insurance policies that cover dental expenses:
- Bajaj Allianz Health Guard Policy
- Apollo Munich Maxima Health
- Bharti Axa Smart Health
- ICICI Prudential Health Saver
- SBI Life Smart Insurance
ANS: Here are a list of health insurance policies that cover pregnancy-related medical expenses:
- Easy Health Family Floater by Apollo Munich
- ProHealth Plus Plan by Cigna TTK Health Insurance
- Total Health Plus by Royal Sundaram Master Product
- Star Health Wedding Gift Pregnancy Cover
- Heartbeat Family Floater by Max Bupa
ANS: Here are a list of top mediclaim policies for families in India:
- Family Floater Mediclaim Policy by New India Assurance
- National Insurance Mediclaim Policy by National Insurance Company
- Family Floater Health Guard by Bajaj Allianz
- Family Health Optima Insurance Plan by Star Health and Allied Insurance
- Family Medicare Policy by United Health Insurance