What is Mediclaim Insurance?

14 March 2023
7 min read
What is Mediclaim Insurance?
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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 prefer 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 Rupees.

It is essential to buy a Mediclaim Policy to take care of such expenses and protect one's Capital.

In the general insurance domain, public and private sector companies, including standalone Health Insurance companies, provide this product.

Understanding Mediclaim Policy

Under a Mediclaim policy, the basic cover provides for the following.

  1. A minimum of 24 hrs hospitalization (admitted to the hospital ) is required to trigger a claim under the Policy.

    There are exceptions to this where specific procedures are done during daycare like Eye Surgery, Angioplasty, etc., where the patient is admitted and discharged the same day.

  2. Expenses incurred 30 days before hospitalization and 60 days post hospitalization.

  3. Coverage only for Allopathic Treatment. Of late, Insurers are also covering Ayurvedic and Unani Treatment in Govt hospitals or Pvt if approved by Quality Council or Accredited by the National Accreditation Board of Health.

  4. Room Rent, Doctors' Fees, Nursing Charges, Cost of Medicines, Operation Theatre charges, Surgical appliances, Laboratory / Diagnostic Tests, and implants like Stents, pacemakers, etc., are paid.

  5. There may be a cap on Room Rent & ICU, like 1 % and 2% of the Sum Insured.

  6. Typically there is a cap on Treatment for ailments like Cataracts, Henia, hysterectomies & other daycare treatments ranging from 10 % to 30% of the Sum Insured.

Benefits of Mediclaim Insurance Policy

A mediclaim health insurance policy has several advantages.

A mediclaim policy facilitates seamless cashless hospitalization and the convenience of having your insurance company handle any expenses incurred due to hospitalization and required treatment.

There are a variety of financial advantages to having mediclaim insurance. It reduces out-of-pocket payments because your insurance provider pays for these medical costs. A mediclaim health policy also protects you from financial hardship in the event of illness.

Additional tax breaks are available for mediclaim insurance and the opportunity to acquire insurance plans online/add-ons to your existing mediclaim insurance online.

Exclusions in Mediclaim Policy

As comprehensive as a Mediclaim policy can be, certain aspects of treatment are not included in the policy. Some of the standard exclusions include:

  • Pre-existing illnesses are covered after the completion of the waiting period

  • Plastic Surgery and Cosmetic Surgery

  • External devices like a hearing aid or contact lenses

Irrespective of the type of Mediclaim policy you buy, read the policy documents carefully and understand the terms and conditions.

Knowing the terms and conditions will help you make an informed buying decision and get the best coverage to suit your needs.

Who Should Buy?

Anyone who wants to protect themselves and their family against health difficulties should consider buying Mediclaim coverage.

Protecting yourself from escalating healthcare expenditures is critical regardless of marital status or life stage. As a result, having a solid financial support structure in place for such charges can be highly beneficial.

How to Choose the Right Mediclaim Policy? 

Although there is no magic formula for choosing the most significant Mediclaim policy, the first step should be to examine your needs.

For example, if you are buying Mediclaim for family members, first evaluate their medical needs, after which you can explore the following to make a knowledgeable choice-

  • Adequate Cover - Select a sufficient sum insured/coverage amount when buying Mediclaim for your family. It is critical since you want to avoid being caught off guard in the event of a medical emergency.

  • Co-Payment Clause - Review the co-payment clause since you may be obligated to pay a share of the sum while claiming the Mediclaim policy. This clause can catch policyholders off guard at times, resulting in disappointment. To prevent this from happening, make sure you thoroughly read the policy document.

  • Compare Plans - Just like any other policyholder, you want to choose plans that provide the most benefits at the most affordable price.

    Comparing different Mediclaim insurance can provide detailed information about the benefits and a clearer picture of your objectives. Choose insurance with no waiting time, especially if you purchase Mediclaim to treat a catastrophic disease.

  • Check Network Hospitals - It is best to invest in Mediclaim, which has an extensive hospital network and cashless payment options. It will make it possible to get vital healthcare in any region of the country without having to worry about the expense.

  • Although most Mediclaim policies do not provide add-on coverage if you can locate one that does, get it.

  • If possible, buy Mediclaim with long-term or lifetime renewability because renewing the coverage yearly can be time-consuming.

  • Lastly, invariably verify the exclusions, limits, as well as sub-limits.

Restrictions

  1. Any hospitalization within the first 30 days of taking the Policy except in case of an accident
  2. There is a 30-day waiting period for any disease contracted when the Policy is first taken, so not payable.
  3. Specific ailments like Cataracts, Gall Bladder Stones, Hydroceles, Internal Congenital disease, etc., are not covered in the first year or two years when the Policy is first taken.
  4. Pre – Existing Diseases like BP, Diabetics, and ailments arising from them are not covered. Depending on the Insurer, these are covered after 2/3/4 years.
  5. OPD treatment is not covered.
  6. Circumcision, plastic surgery, etc. not covered unless it is medically required.
  7. Contact lenses, spectacles, hearing aids, etc., are not covered.
  8. Dental Treatment, Maternity, Naturopathy, and AIDS are not covered.
  9. General Debility or run-down condition, or medical check-ups are not covered.

Types of Policies

  • Individual Sum Insured

The Sum Insured limit per person in the Policy is defined.

For example, 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 example, the Proposer may have Rs 5 lacs, his wife Rs 2 lacs, and each of the children Rs 1 lac.

  • Floater Sum Insured

Where the Total Sum Insured covers the whole family, one person or all put together can claim the Sum Insured in full.

For example, A family of husband, wife, and two children. In case one of them is hospitalized, and Bill is Rs2 lacs. Next, if the husband is hospitalized in the year, the amount available for the claim is a Maximum of Rs 3 lacs.

  • Senior Citizen Mediclaim Policy

Senior citizen mediclaim policy is a mediclaim policy that provides coverage to people over the age of 55.

  • Critical Illness Mediclaim Policy

While dealing with life-threatening diseases such as cancer, kidney failure, heart disease, etc., hospital expenses swiftly drain your finances.

Critical illness mediclaim coverage helps reduce those costs by providing a lump sum upon disease diagnosis.

  • Mos-Bite Protector Mediclaim Policy

This policy will pay you a lump sum if you are diagnosed with vector-borne diseases such as Malaria, Dengue fever, Chikungunya, or Zika virus.

Personal Accident Mediclaim Policy - This mediclaim coverage protects against accidental death, total permanent disability, partial permanent disability, and temporary total disability.

  • Hospital Daily Cash Mediclaim Policy

This mediclaim plan assists you in meeting your daily cash needs in the event of a hospitalization.

  • Health Top-UP Mediclaim Policy

This form of mediclaim is helpful if you already have health insurance and use this policy to gain additional coverage cheaply.

Renewal of Policy

A critical condition under the national 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, seven days may be given only on solid grounds like traveling outside the country or being hospitalized.

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.

Conclusion

According to statistics, approximately 427 million Indians were insured under multiple mediclaims and health insurance policies in the past fiscal years.

Mediclaim plans are vital for each individual or family since they provide a wealth of benefits that could prevent a financial or medical disaster in the future, even if the payoff appears to be minor in the immediate run.

You May Also Be Interested to Know-

1.

The Life and Health Insurance Checklist

2.

Everything You Should be Knowing About Insurance Premium

3.

Best Health Insurance Plans in India

4.

Best Term Insurance Plan in India

5.

Best Child Insurance Policies in India

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