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.
- 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.
Cashless claimsIn 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.
News About Mediclaim Policy
General Insurance Companies Post Double Digit Growth in Direct Premium Collections
The total direct premiums mopped up by general insurance companies in India was up by 12.9% (YoY) in the month of July 2016. Players from the private segment posted higher growth when compared to their public sector counterparts. The industry posted a consolidated premium income of Rs.8,986.56 crore as compared to Rs.7,958 crore recorded during the same month last year. While the public sector insurance companies posted an overall premium income of Rs.4,502.85 crore, private players registered Rs.3,948.72 crore.
Demand from the marine and engineering sectors has been a driving force behind sound growth for private general insurance companies. It must be noted that private insurance companies have an upper hand in motor and fire insurance segments. Health insurance companies also saw premium income going up by 32.7% in July.
29th August 2016
Government to take action against insurance companies violating norms
Health Insurance in the country remains a key issue, with a major portion of our population falling outside the ambit of its protection. Even despite these low figures, the number of companies offering insurance products has increased, with international players entering the fray. A recent analysis has revealed that a number of companies are violating laws, offering insurance products which they are not allowed to. The government has taken notice of such issues and is planning action against them, aiming to reign policies and streamline the process. Investigation is being carried out with this regard, with a few companies being fined for the same.
The government has identified 13 such companies who have violated existing norms. Popular names like Bharati Axa General Insurance, New India Assurance, Future Generali Insurance, Bajaj Allianz General Insurance, L&T General Insurance, Max Bupa Health Insurance, Shriram General Insurance, United India Insurance, ICICI Lombard, Reliance General Insurance and Cholamandalam M S General Insurance are part of this list.
10th August 2016
Religare would be realigning its capital markets, finance and health insurance businesses
Religare Enterprises Ltd., would be reorganising the structure for three of its businesses, namely, health insurance, capital markets and finance. These three businesses would be listed as separate entities. The Religare management would be making the required changes within the next twelve months and would be accepting partnerships from investors. An in-approval for the same has been given by the Religare board. JP Morgan would be helping Religare complete the restructure. As a part of this, Religare would be selling its asset management business and its stake in the healthcare private equity firm, Quadria Capital. Further, Religare’s stake in YourNest might also be sold in the near future.
1st June 2016
Kozhikode Municipal Corporation plans health cover for waste collectors
In an innovative and thoughtful move, the municipal corporation of Kozhikode has come up with a brilliant initiative to provide health insurance cover to workers engaged in door-to-door waste collection. These workers are known and Kudumbashree workers and are essential to the waste management system in Kozhikode.
The civic body is of the view that with the introduction of health and accident insurance to these workers, the number of workers who quit citing health issues will go down. The planned health insurance scheme will be launched under the annual program for the current financial year. The number of workers has gone down from 750 in the year 2000 to 342 currently. Majority of these workers had to quit due to health ailments which are quite common due to exposure to unhygienic conditions.
27th May 2016
A $500 million insurance fund announced by World Bank
World Bank has provided a $500 million insurance fund to help weaker nations to tackle deadly pandemics. As the first of its kind, the insurance fund has been named as Pandemic Emergency Financing Facility (PEF) by World Bank. World Bank Group had been requested to create such a fund by the G7 leaders during the May 2015 summit in Germany. World Bank has made this announcement just before the Summit of Group of Seven Leaders happening on May 26 & 27 in Japan.
The insurance fund that is being offered in collaboration with the World Health Organisation (WHO) and other private companies will cover up to $500 million for a period of three years, after the outbreak of a major epidemic. World Bank would be offering expert teams and funding to countries from where pandemics have been reported. This announcement comes in response to the outbreak of the Ebola pandemic in Sierra Leone, Liberia and Guinea. The outbreak had costed a $2.8 billion loss to the economies of these countries.
24th May 2016
Goa Health Insurance Scheme to Exclude Govt. Employees, Kin
The Deen Dayal Swasthya Seva Yojana which is about to be launched by the end of May has excluded more than 50,000 families that have at least one member working in a governmental institution. The scheme will cover another 3.5 lakh families that do not have members working for the government. The exclusion has been done because families of government staff already receive medical expenses reimbursement under a different scheme. The new Yojana will rely heavily on Aadhar Cards to collect valuable data, which is made easier as Goa has more than 96% enrolment in Aadhar. United India Assurance is the primary mover of the scheme, with premiums as low as Rs.200 for a three member family and Rs.400 for families of four and more.
23rd May 2016
2016 Draft National Policy Released - Emphasis on Health Insurance, Security
The Draft National Policy for Women 2016 was released on 17th May by Maneka Gandhi, Union Women and Child Development Minister. The new policy will replace the existing framework under National Policy for Empowerment of Women and set the government’s path towards women development over the next two decades. The policy provides a much needed shift to rights from entitlement and creation of enabling environment rather than empowerment. The scheme also aims to expand the health insurance ambit for women so that overall cover, maternity and child care are also being included.
20th May 2016
Bank of Baroda and Max Bupa Insurance tie-up!
Leading health insurer, Max Bupa and Bank of Baroda entered into a bancassurance tie-up on Saturday. According to the tie-up, Max Bupa will be offering comprehensive health insurance to the customers of Bank of Baroda all across the country. IRDAI recently issued bancassurance guidelines according to with leading banks can tie up with various insurers to distribute insurance products to increase the margin of health insurance in the country. Max Bupa will be providing customisable product variants with sum assured ranging from Rs.50,000 to Rs.1 crore in the initial phase.
10th May 2016
IEEE members in India entitled to enjoy health insurance benefit program
IEEE members who are currently staying in India can now enroll themselves in a group medical insurance program sponsored by IEEE. As per this program, the primary policyholder gets a comprehensive health insurance benefit for his/her family. This also includes the member’s dependent parents or in-laws.
For members aged between 18 and 85 years, they are eligible to apply for the coverage. They are entitled to decide their coverage level ranging from 200,000, 300,000, 500,000, 700,000, or 1 million rupees.
The program is also designed to cover dependent children, but only up to an age of 25. In case of dependent parents/in-laws, the upper age limit is that of 85 years. It needs to be noted that the program covers only pre-existing medical ailments and policyholders get a waiver in medical tests.
28th April 2016
Madhya Pradesh shows Poor Track Record for Reimbursement of Medical Claims
Madhya Pradesh adds another item to its list of woes and shortcomings. Not only is the state a poor place for medical treatment but records show the state to be have one of the worst track records when it comes to reimbursing medical expenses
According to the latest report carried out by the National Survey Sample Office (NSSO), only six people per thousand patients have received a reimbursement either in part or in full in the entire state.
This comes as a shocker due to the higher end of average medical expenses incurred especially in rural areas where the average cost of medical treatment stood at Rs 18,696 and in January to June of 2014, the number of expenses that were reimbursed in rural MP either in part or in full was one patient per thousand patients.
19th April 2016