Mediclaim policy in India is taken to take care of Hospital Bills in case a person is admitted to the hospital. Many of us would avoid going to a Govt hospital and rather prefer going to a Privately owned hospital mainly for better care and facilities. But then these come with a cost. Minor surgery in a hospital will cost at least Rs 20,000/- and major ones like heart Bypass, Knee replacement etc cost lacs of Rupees.
To take care of such expenses and to protect one’s Capital it is important to buy a Mediclaim Policy. In the general insurance domain, both public and private sector companies including stand-alone Health Insurance companies are providing this product.
Under a Mediclaim policy, the basic cover provides for the following
The claim is paid in two ways. Either it is a cashless treatment where the TPA pays directly to the hospital or a reimbursement case wherein the insured pays himself and takes reimbursement from TPA by submitting all original papers relating to the treatment
Once the Premium has been paid, the Insurer Issues the Policy. The Policy is serviced by an external agency called TPA which issue the medical cards and make payment to the hospitals in case of a claim. However, some Private Insurers and standalone health Insurance companies make use of In house claims settlements.
Hospitals empanelled by TPAs across the country for cashless treatment. Where Treatment is taken in a Non-Network hospital, payment is made on a reimbursement basis provided it fulfils the condition of a Hospital.
Definition of Hospital / Clinic
An establishment that has
A condition in policy whereby the insured is required to bear a certain percentage of the claim by himself. This is generally imposed where Policyholder is above 60 years of age and varies from Insurer to Insurer.
You may also want to read, The Life and Health Insurance Checklist
Sum Insured limit per person in the policy is defined. For e.g an individual in a policy, the Sum Insured for Rs1 lac, Rs 2 lac etc. If family members are covered in the policy then Sum Insured for each person is defined. For e.g. Proposer may have Rs 5 lacs, his wife Rs 2 lacs and each of the children Rs1 lac.
Where the Total Sum Insured covers the whole family. One person or all put together can claim the Sum Insured in full. For e.g. A family of husband, wife and two children. In case one of them is hospitalised and Bill is Rs2 lacs. Next, if suppose the husband is hospitalised in the year the amount available for the claim is a Maximum of Rs 3 lacs.
This is a Policy taken in Addition to an insurance policy mediclaim which specifies a minimum expense threshold to make a claim under the policy. This can be from the same Insurer or any other insurer.
A very important condition under Mediclaim insurance policy is that it must be renewed on or before the due date. Unlike a Life policy where a Grace period of 30 days is given, in Mediclaim 7 days grace period may be given only on solid grounds like travelling outside the country or being hospitalised etc. The implication of not renewing in time is that the policy is treated as a fresh one and limitations of pre-existing diseases will apply afresh.
The Policyholder is free to renew his Mediclaim policy with an Insurer of his choice and will be considered as continuous renewal protecting the pre-existing disease cover and this is done through the IRDA portal.
Insurance Regulatory and Development Authority is the market regulator which is vested with powers of licencing and regulating the Insurance market in India.