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All That You Need to Know About Mediclaim Policy in India

26 June 2022, 1:47 AM

Mediclaim insurance policy in India is a health insurance policy that is designed in such a way that it can meet the expenses for your healthcare up to the sum insured of the policy. This can happen if you have been hospitalised due to some illness, some accident, or for facing any kind of medical emergencies. The benefits of a Mediclaim insurance policy can be obtained by making the payment of the annual premium.

In a mediclaim insurance policy, the expenses which are incurred in hospitalisation can either be reimbursed or can be settled by the cashless method. The Mediclaim insurance policy in India can be issued for a particular period. When the renewal date of the Mediclaim insurance policy is due, you must pay the premium before the due date for availing of the benefits.

Salient Features and Benefits of Mediclaim Insurance Policy  

The major features and benefits of the Mediclaim insurance policy in India can be listed below.

  1. Mediclaim insurance policy offers cashless hospitalisation and it can be purchased easily by online means.
  2. You can purchase this policy for yourself or for the protection of your family members. So, mediclaim policies are available as individual policies and family floater policies as well.
  3. The insurance providers would be handling the expenses incurred in the hospitalisation thus, reducing the financial burden on you and your family.
  4. Mediclaim policies also help you in availing tax benefits on the premium paid for the policy under Section 80D of the Income Tax Act, 1961.

Inclusions in a Mediclaim Insurance Policy

A good Mediclaim insurance policy would help you in providing coverage for a large range of medical care and facilities. Let us check out the major areas which are covered under a Mediclaim insurance policy.

  1. Mediclaim policies offer cover for the hospitalisation expenses of you and your beneficiaries. These expenses can include procedures related to medicines, X-rays, blood tests, diagnostics, OT charges, etc.
  2. Mediclaim policies offer cover for pre-hospitalisation and post-hospitalisation expenses. Coverage for 30-60 days of pre-hospitalisation is and coverage for 60-120 days of post-hospitalisation expenses is available under the Mediclaim insurance policy.
  3. Mediclaim policies in India would also offer coverage for the expenses incurred in day-care hospitalisation i.e. expenses incurred in those treatments which do not need hospitalisation of 24 hours.
  4. Mediclaim insurance policy offers additional benefits such as coverage for expenses related to ICU, AYUSH treatments, annual health check-ups, etc.
  5. Expenses incurred in the consultation of specialist doctors or medical professionals would also be covered under the Mediclaim policies.

Different Types of Mediclaim Policies 

The different types of Mediclaim policies available in India are mentioned below.

  • Individual Mediclaim Insurance Policy – In this policy, only you as the policyholder would be provided coverage against the medical expenses incurred in hospitalisation.
  • Group Mediclaim Insurance Policy – A Group Mediclaim insurance policy would be purchased by your employer to provide you and other employees with financial coverage against medical expenses.
  • Family Floater – In a family floater health insurance plan, you, your spouse, your parents, and your children would be covered against expenses incurred due to hospitalisation.
  • Critical Illness Mediclaim Insurance Policy – The expenses that are incurred in the treatment of critical illnesses is quite high. The Critical Illness Mediclaim insurance policy would provide cover against expenses incurred in the treatment of ailments such as kidney failure, cancer, and other serious ailments.
  • Senior Citizen Mediclaim Insurance Policy – Under senior citizen Mediclaim insurance policy, coverage would be provided to the senior citizens along with special provisions.
  • Overseas Mediclaim insurance policy – By this Mediclaim insurance policy, you can make claims against the expenses which have been incurred due to hospitalisation done overseas.
  • Low-cost Mediclaim Insurance Policy – If you are looking for a low sum insured and low-cost Mediclaim insurance policy is the best option for you. These policies are usually purchased by the underprivileged and by small/medium scale employers for their employees.

Exclusions of Mediclaim Insurance Policy

There are certain exclusions for the Mediclaim policies and these exclusions can be different for different insurance providers.

Some of the major exclusions of the Mediclaim policies in India are mentioned below.

  • Expenses related to maternity if they have not been taken as an add-on
  • Pre-existing conditions
  • Vaccinations
  • Treatments related to cosmetic surgeries and dentists
  • Any hormonal treatment or treatment related to birth control
  • Sexually Transmitted diseases
  • Any disease which has been contracted by you within a particular period from the date of policy purchase
  • Expenses that are non-medical such as the service charges, administrative charges or charges related to toiletries, etc.

Procedure for Making Claims in Mediclaim Insurance Policy

In Mediclaim insurance policy, claims are mainly of two categories i.e.

Cashless Procedure

The cashless claim settlement procedure of Mediclaim insurance policy would include two scenarios: -

  • Cashless Claim for Planned Hospitalisation – In this process, you would have to collect details about the hospitals which are present in the network list of your insurance provider. You will have to select a hospital from this list where you are planning to get admitted. There would be an insurance desk in the network hospital to help with the procedure related to claim settlement. You would have to collect a pre-authorisation form from the insurance desk, fill it and deposit at the desk. After this, the filled form would be signed by the doctor and stamped by the hospital authorities.

After the formalities are completed, the form would be sent to the TPA of your mediclaim insurance company. Your insurance provider or the TPA will do an evaluation of the filled form and sanction a certain sum. The fax would be sent to the hospital authorities from your TPA or insurance provider about the sanction of the amount for cashless hospitalisation.

  • Cashless Claim for Emergency Hospitalisation – If the hospitalisation is occurring on an emergency basis, you would not get adequate time for filing the form and completing other formalities. You will have the time of 4 hours post hospitalisation to fill and send the pre-authorisation form. It is wiser to always carry your mediclaim proof as accidents are quite unprecedented.

Reimbursement Procedure

If you are opting for a reimbursement procedure, then it is necessary that your insurance provider is kept informed about the hospitalisation. You will have to systematically maintain track of all expenses incurred. You must keep your bills properly arranged. You must fill up a claims form with proper information and send it to your insurance provider along with the bills. You should not try to make any false claims as that can lead to claim rejection. In case, the insurance provider rejects your claim, you would ask for a proper explanation related to the cause for rejection of the claim. 

Factors to Keep in Mind While Buying a Mediclaim Insurance Policy

Some of the important points which you must keep in your mind while purchasing a mediclaim insurance policy are 

  • Sum Insured – The sum insured for your Mediclaim insurance policy must be adequate. You can opt for a high sum insured by paying high premiums, but the sum insured should be according to your requirements.
  •  Co-payment – You must understand clearly about the clause of co-payment. You would have to pay out a particular percentage of your claims and the remaining percentage would be paid off by the insurance provider.
  • Waiting Period – You must know about the waiting period before which you cannot make any type of claims with the insurance provider. 
  • Add-ons – Usually, insurance providers will not offer riders as a part of  Mediclaim insurance policies. However, riders can be included as an additional feature into your insurance policy along with the payment of an additional premium.
  • Network Hospitals – You should try and select an insurance provider whose range of network hospitals is quite wide. This is because you can avail of cashless hospitalisation only in the case of network hospitals.

Conclusion

So, mediclaim policies can also be known as a policy providing hospitalisation benefits. You must understand your requirements, compare the policies online, and then purchase your online mediclaim insurance policy. 

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