What is Mediclaim?
Mediclaim is an insurance product that reimburses the expenses you incur in the event of hospitalization or domiciliary care. It can either reimburse your expenses when you submit relevant bills, or enable you to have an entirely cashless hospitalization where your insurer will directly deal with the hospital – letting you focus on treatment and healing.
Ever increasing cost of healthcare and lifestyle diseases has made it necessary for individuals to have health insurance in India. Mediclaim policy is health insurance policy that offers health cover up to the sum insured in the case of an illness or accident leading to hospitalisation. Mediclaim policy in India is issued for a specific time period. The policy has to be renewed for continued benefits.
- Premiums – that are payable on Mediclaim policies differ between insurers but are based on certain criteria like age of the proposer, geographical area of treatment, sum insured, term of plan, etc.
- Age – of insured persons can range from 5 years to 80 years, although age criteria and range insurable varies between companies.
- Family cover – You can provide Mediclaim cover for your entire family with the payment of one master premium. This may also make you eligible for discounts on your premium, depending on your provider.
- Overseas Mediclaim Policies – A large number of insurance companies offer Mediclaim policies that cover you in India and overseas, subject to certain predetermined conditions.
- Claims – are administered largely through Third Party Administrators (TPAs) these days, but a few insurers deal with claims in-house.
- Types – Mediclaim policies are available in a range of types, depending on the need and the category of those to be insured. You can get individual policies, group policies, senior citizen policies, critical illness policies and special maternity policies.
- Tax benefits – under Section 80D are available up to Rs.15,000 on mediclaim premiums for yourself, spouse and dependent children. An additional Rs.15,000 of tax exemption is available if you insure your parents, and the amount goes up to Rs.20,000 if they are senior citizens.
How is Mediclaim Different from Health Insurance?
Insurance companies offer health insurance products under two broad categories – indemnity policies and benefit policies:
- Benefit policies are mostly traditional health insurance policies which pay out a pre-determined “sum insured” amount on the occurrence of an accident, or diagnosis of any of the illnesses, diseases, conditions, etc. that have been insured against. Traditional insurance policies work this way, offering you a financial benefit up-front and not necessarily requiring you to submit hospital bills, etc.
- Indemnity policies compensate or reimburse you for the expenses incurred during your hospitalization or domiciliary care, on the submission of necessary proofs, up to the limiting amount mentioned in the policy. Mediclaim is an example of such a product. Although with recent advancements, mediclaim enables cashless hospitalization facilities wherein the insurer pays the hospital directly.
The most important difference between mediclaim and health insurance is that mediclaim will only reimburse your expenditure, and not provide you with a large-sum financial benefit in case you are rendered unable to earn.
Types of Mediclaim Policies in India:
- Individual Mediclaim - where you basically insure yourself against the financial liabilities of hospitalization.
- Family Floater - where you can provide additional coverage for your entire family, and be tension-free in matters of hospital bills and related expenses.
- Group Mediclaim - where an employer or person in charge of a group of people wishes to add to their remuneration the benefits of cashless hospitalization and / or reimbursement on hospitalization expenses.
- Overseas Mediclaim - where all your hospitalization and related expenses are taken care of during your stay (or travel) outside India.
- Low-cost Mediclaim - is for the underprivileged masses. Employers of small-scale and medium-scale industries insure their employees and their dependants for as low as Rs. 1,600 per annum.
- Senior Citizen Mediclaim - while this type of mediclaim requires testing and/or special provisions, it’s a huge step forward for the industry as they can safely insure senior citizens at competitive premium rates.
- Critical Illness Mediclaim - among the most expensive treatments in the field today are those incurred on treatment of critical illnesses. Critical Illness Mediclaim policies usually offer a higher claimable amount, and include some of (but are not strictly limited to) the following:
- Aorta graft surgery.
- Coronary artery bypass surgery.
- First heart attack.
- Kidney failure.
- Major organ transplant.
- Multiple sclerosis.
- Primary pulmonary arterial hypertension.
What does a Best Mediclaim Policy Cover?
Mediclaim policies offer excellent benefits and coverage for a wide range of expenses, depending on your insurance provider. Mediclaim policies in general offer the following benefits and cover:
- Hospital charges – all direct charges that you incur as a result of hospitalization like OT charges, medicines, blood, oxygen, diagnostic material, x-rays, chemotherapy, radiotherapy, pacemakers, donor expenses during organ transplants, etc.
- Day-care treatment – expenses towards specified technologically-advanced treatments where 24-hour hospitalization is not needed.
- Pre and post-hospitalization expenses – for a period of 30 days before and up to 60 days after hospitalization and may include assistance in availing emergency services like ambulance, etc.
- Hospital accommodation charges – in regular wards or in ICUs are fully reimbursed, or taken care of with the cashless hospitalization facility.
- Medical professional’s fees – like doctor’s fees, nurse’s fees, anaesthetist's charges, etc.
- Investigation charges.
What Does Mediclaim Policies not Cover?
Different providers have different exclusions in their policies, some may not even consider the standard exclusions and provide benefits anyway. Nevertheless, a standard Mediclaim policy would not cover you for treatment or expenses arising from or attributable to the following:
- All pre-existing diseases, medical conditions and injuries that are present before the policy comes into force.
- All diseases and medical conditions (unless otherwise specified in your policy document) that arise within the first 30 days of your policy commencement date.
- Injuries or medical conditions caused by war (whether it be declared or not), hostile foreign invasion or attack, war-like operations, etc.
- Plastic surgery and circumcision (which is not necessary as treatment for illness or accident), cosmetic or aesthetic treatments of any kind.
- Cost of spectacles, hearing aids, contact lenses, etc.
- Dental treatment and surgery whether it is corrective, cosmetic or aesthetic – unless it arises due to an accident and requires hospitalization.
- Intentional self-injury and attempted suicide.
- Alcohol / drug abuse.
- STDs like HIV / AIDS, human T cell lymphotropic virus type III (HTLB III), lymphadenopathy associated virus (LAV) or their variations.
- X-rays, laboratory tests and other expenses incurred not in direct relation to the treatment.
- Injury or disease arising from nuclear radiation or exposure to nuclear weapons and materials.
- Pregnancy, childbirth, miscarriage, abortions, caesarean section, etc. or any complication arising from these.
- Nautropathy related treatments.
How do I Claim the Benefits of My Mediclaim Policy?
It is important to keep the insurer or the TPA informed of your hospitalization as and when it happens. This is important because insurers and TPAs have a very strict definition of the term “hospital” and will not honour claims for treatment received in medical facilities that fall outside their definitions. It’s important to know which hospitals are in their list, before being admitted.
Upon hospitalization, you must keep a careful tally of all expenditures and maintain records of all bills that you have been given. Don’t take a high-end room and lavish hospital facilities if you can’t afford it without insurance (as insurers will scrutinize these claims and judge whether that extra-comfortable hospital bed was a vital requirement for your recovery). Avoid listing personal comfort items as they will most likely not be honoured.
Fresh approval needs to be sought for changes in treatment. If you are being treated for an injured leg, the insurer will reimburse the x-ray costs for your leg, but if you develop a headache and require a CT scan, another approval will be required for this.
You will need to fill up a claim form clearly and without any ambiguity or falsehoods (as any of these could set your reimbursement back by weeks, even months). Keep your hospital bills available upon request and attach the same to you claim form and submit it to your insurer. A clean and duly filled up claims form with all necessary attachments easily available will help you a lot.
There are instances where insurers do not honour claims and give very vague reasons for the same. In case your claim is denied for any reason, ask the insurer for a detailed explanation as to why it was rejected with specific clause numbers and details. This will help you take the matter up in a relevant consumer forum or even legal court, if necessary.
In order for the insurer to process your claim, you will need to fill in a detailed “preauthorization request form” and submit the same to the company.
Cashless Planned Hospitalization:
If you have time to plan your admission to the hospital, you need to send your preauthorization at least 72 hours before your actual hospitalization. This results in a smooth, cashless mediclaim experience.
Cashless Emergency Hospitalization:
In an emergency like a car accident, there won’t be time to send a preauthorization, etc. In such a situation, you need simply produce your Medi Assist ID Card at the network hospital. This will facilitate cashless hospitalization and get you four hours in which you must send your preauthorization request. As we can see here, it’s important to carry your Medi Assist ID Card with you at all times.
What should I Look for when Choosing the Right Mediclaim Policy?
Choosing the right insurance policy today means navigating a maze of providers and heavily scrutinizing the hundreds of plans available. There are plans which provide the best and most comprehensive cover, but will cost you a high premium, and those which give you skeletal cover for a paltry premium, primarily used for securing benefits on income tax. In addition to this, there are riders that provide different covers and benefits but may overlap in their features, making you pay more per rider, for overlapping benefits.
It’s important to look at sub-limits in your policy documents. A sub-limit is a method by which insurers are limiting their liability in a world of rising healthcare costs. For example, if your sum insured amount is Rs.1 lakh and your sub-limit for room rent is 1%, the insurer will only cover Rs.1,000 under your “room rent” expense heading. If your room costs, say, Rs.1,400 – you will have to pay that extra Rs.400 from your own pocket.
Tick off parameters in the following checklist:
- Sum assured and coverage required.
- Do you need maternity benefits?
- Do you want to pay regular premiums or a single premium?
- What are the sub-limits specified for various expenditures?
- Do you want a traditional health insurance lump sum benefit, or just want your hospital bills reimbursed?
- Up to what age do you want to renew your policy?
- What is the range of eventualities you want covered in terms of critical illnesses?
- Does it have enhanced features like cashless claims, quick processing, etc.?
- How does it rank in terms of customer service?
- What is their claim settlement ratio?
Your answers to these simple questions could help you make your decision based on your personal requirements.
Compare and Buy Mediclaim Policies Online:
It is strongly recommended that you take a Mediclaim policy for every member in your family, including children (perhaps through a family floater), as it is one large policy that covers everyone under it. It’s an excellent alternative to taking separate health insurance policies, as Mediclaim requires the payment of only one premium.
It is important to note that Mediclaim is not an alternative for a life insurance policy as it will not provide a benefit in case the earning member of the family is rendered unable to earn anymore. Look for the right balance between benefits offered, ease of claim settlement, and cost of premiums to find the right policy for you.
Benefits of Buying a Mediclaim Policy:
Medical expenses can put a dent in your pocket if you don't have a suitable health cover to pay your hospitalisation costs. Mediclaim policy is the most common health insurance policy available in India. Your health insurance policy can ensure you receive timely and adequate healthcare without worrying about putting a huge dent in your pocket. Here are some benefits of purchasing a mediclaim policy:
- It is a cost-effective solution to afford adequate healthcare.
- It reduces the financial burden faced by an individual in the event of a sudden illness or accident that leads to hospitalisation.
- Mediclaim policy offers cashless hospitalisation wherein the insured member doesn't have to pay for medical expenses upfront. The insurer will pay for the treatments received at a network hospital.
- Cashless mediclaim policy ensures you don't have out-of-pocket medical expense. Instead, the medical expenses will be paid for by the insurance company.
- You can get tax deductions on premiums paid towards a mediclaim policy for self, spouse, and children under Section 80D of the Income Tax Act, 1961, for a maximum of Rs.15,000. You can get another Rs.15,000 tax benefit on premium paid towards a mediclaim policy for parents, Rs.20,000 if parents are senior citizens.
Points to Consider When Buying a Mediclaim Policy:
To choose the right mediclaim policy, keep the following points in mind:
- Health insurance coverage: Selecting the right mediclaim policy is important so as to avoid ending up with insufficient health cover. Pick sufficient sum insured to cover all your medical expenses.
- Co-payment: A health insurance policy with a co-pay clause is one where the policyholder agrees to pay a part of the medical expense out of his or her pocket while the insurance company pays the rest. Co-pay can reduce the insurance premium of your mediclaim policy. It is a common feature in senior citizen health insurance policies.
- Treatment specific limits: Insurers levy limits on certain medical treatments like cardiac treatments or cataract. Before purchasing the policy check for any treatment specific limits.
- Waiting period: Health insurance policies have an initial 30-day waiting period for all illnesses except in the case of an accident that leads to hospitalisation. Pre-existing disease cover usually begins after a 4-year waiting period. During the waiting period, policy benefits can't be availed. Therefore, it is important to check waiting period clause of the policy.
- Network hospitals: Cashless hospitalisation facility can be availed only at a network hospital of the insurance company. Check the list of network hospitals in your location.
- Maternity cover: Pregnancy related medical expenses are usually not covered by regular health insurance policies. Therefore, check if your insurance providers offers maternity cover and what is including in the coverage.
- Exclusions: Read the policy document carefully, especially the exclusions of the policy. Exclusions usually include suicide attempts, dental treatments, self-inflicted injuries, alcohol or drug abuse, etc.
- Free-look period: Go through the terms and conditions of the policy during the free-look period, if you have any objections, you have the option to return the policy within the free-look period, and get a refund on the premium paid after certain deductions.
How Does a Mediclaim Policy Works?
Many organisations in India offer mediclaim policies to their employees as an incentive to retain talent in the company. Mediclaim policy basically covers the hospitalisation costs during the policy term. The insurance premium depends on the sum assured of the policy. In addition to hospitalisation costs, mediclaim policy also covers domiciliary hospitalisation.
Most insurers offer customised mediclaim policies to suit the size and requirements of the organisation. In addition to group mediclaim policy, there are mediclaim policies for individuals, couples, and families. Mediclaim policies can be purchased by paying the cost of the insurance plan upfront or in instalments.
Checklists Before Buying a Mediclaim Policy:
Here is a 10-point checklist before buying a mediclaim policy:
- Buy a health insurance policy before it's too late: It is advisable to purchase a health insurance policy with a lifelong renewability option when you are young and in good health so that you may be covered when you need it the most. You can accumulate no-claim bonus with every claim-free renewal over the years. There is an age limit on purchasing a health insurance plan. Moreover, senior citizen health insurance plans can be restricting compared to regular health insurance plans.
- Assess who in your family needs health cover: In the case of a family insurance plan, the sum insured is shared by the entire family which is why it is important to assess who needs health cover and their health condition at the time of purchasing the policy. The insurance premium of a family floater plan depends on the age of the eldest member of the family. If there are members with a medical conditions and are aged above 50 years, there can be certain time-bound exclusions in the policy.
- Keep a check on your health and lifestyle: There is an increase lifestyle diseases due to an individual lifestyle choices and habits like smoking, drinking, and eating out often. Exercise regularly and keep a check on your diet. Avoid a sedentary lifestyle. It can protect you from contracting an illness.
- Determine whether you require an individual cover or a family floater plan: Though a family floater plan is cost-effective, having a high-risk family member as a part of the cover can lead to other members being left without any cover when they need it.
- Choose sum insured on a long-term perspective: When choosing the sum insured don't consider just the current costs of healthcare. Healthcare costs keeps increasing rapidly, therefore consider your insurance requirement on long-term basis, and choose a sufficient sum insured.
- Sub-limit on room rent: Check if your chosen health insurance policy comes with a sub-limit on room rent. For instance, for a health insurance policy with a sum insured of Rs.2.5 lakh, you can stay in a room with a rent of Rs.2,500. Any additional cost on room rent has to be paid by the policyholder out of his or her pocket. The reason for setting a sub-limit is to reduce the liability of the insurer to the policyholder.
- Check for co-pay clause in your chosen policy: If you have an existing policy, review the insurance coverage and determine whether you require additional coverage. If you are dissatisfied with the current insurer, you can transfer your mediclaim policy to a new insurer at the time of renewal.
- Network hospitals of your insurer: Cashless facility can be availed only at one of the network hospitals of the insurer. The list of network hospitals can be found on the insurer's website. Check for the network hospitals in your location.
- Opt for top-up plans: To get a high sum insured for a longer policy term, you can opt for a super top-up plan. For instance, you can chose a base cover of Rs.5 lakh and a super top-up cover of Rs.15 lakh. This can help you save on insurance premium. Ensure you purchase the super top-up plan along with the base policy tenure and same renewal dates.
- Review your existing policy: If you have an existing policy, review the insurance coverage and determine whether you require additional coverage. If you are dissatisfied with the current insurer, you can transfer your mediclaim policy to a new insurer at the time of renewal.
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.
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