Mediclaim policy is taken to take care of Hospital Bills in case a person is admitted to 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. A 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 pvt sector companies including stand-alone Health Insurance companies are providing this product.

Mediclaim Cover

Under a Mediclaim policy the basic cover provides for the following

  1. Minimum 24 hrs hospitalisation ( being admitted in the hospital ) is required to trigger a claim under the policy. There are exceptions to this where certain procedures are done during day care like Eye Surgery, Angioplasty etc where the patient is admitted and discharged the same day.
  2. Expenses incurred 30 days prior to hospitalisation and 60 days post hospitalisation
  3. Coverage only for Allopathic treatment. Of late Insurers are also covering Ayurvedic and Unani treatment in Govt hospital or in Pvt if approved by Quality Council or Accredited to National Accredition Board of Health.
  4. Room Rent, Doctors Fees, Nursing Charges, Cost of Medicines , Operation Theatre charges , Surgical appliances, Laboratory / Diagnostic Tests, implants like Stents, Pacemaker etc are paid
  5. There may be a cap on Room Rent & ICU like 1 % and 2% of Sum Insured respectively.
  6. Normally there is a cap on treatment to ailments like Cataract, Hyrenia, hysterectomy & other day care treatments ranging from 10 % to 30% of Sum Insured.

Restrictions

  1. Any hospitalisation within first 30 days of taking the policy except in case of any accident
  2. There are 30 days waiting period for any disease contracted when policy is first taken and so not payable
  3. Certain ailments like Cataract, Gall Bladder Stone, Hydrocele, Internal Congenital disease etc are not covered in the first year or first two years when the policy is first taken.
  4. Pre – Existing Diseases like BP, Diabetics and ailments arising out of them etc 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, AIDS are not covered.
  9. General Debility or run down condition or medical check ups are not covered.

Claim

The claim is paid in two ways. Either it is cashless treatment where the TPA pays directly to the hospital or reimbursement case  wherein insured pays himself and takes reimbursement from TPA by submitting all original papers relating to the treatment

TPA – Third Party Administrator

Once the Premium has been paid, the Insurer Issues the Policy. The Policy is serviced by an external agency called TPA who issue the medical cards and make payment to the hospitals in case of a claim. However, some of the Private Insurers and standalone health Insurance companies make use of In house claims settlement.

Network Hospital

Hospitals empanelled by TPAs across the country for cashless treatment. Where Treatment is taken in a Non-Network hospital, payment is made on reimbursement basis provided it fulfils the condition of a Hospital.

Definition of Hospital / Clinic

An establishment which has

  1. Qualified Nursing staff round the clock
  2. Qualified Doctor round the clock
  3. Has Minimum 10 beds in small towns ( population less than 10 lacs ) & 15 beds in other towns/cities.
  4. Fully equipped Operation Theatre.

Co Pay

A condition in policy whereby the insured is required to bear a certain percentage of the claim by himself. This is generally imposed where Policy holder is above 60 years of age and varies from Insurer to Insurer.

Types of Policies

Individual Sum Insured

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.

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 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 husband is hospitalised in the year the amount available for the claim is Maximum Rs 3 lacs.

Top Up Policy

This is a Policy taken in Addition to a Mediclaim Policy which specifies a minimum expense threshold to make a claim under the policy. This can be from same Insurer or any other insurer.

Renewal of Policy

A very important condition under Mediclaim 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.

Portability

The Policy holder is free to renew his Mediclaim policy with Insurer of his choice and will be considered as continuous renewal protecting the pre-existing disease cover and this is done through IRDA portal.

IRDA

Insurance Regulatory and Development Authority is the market regulator which is vested with powers of licencing and regulating the Insurance market in India.