Since older people are more prone to health hazards and require comparatively more frequent medical expenses, National health insurance has designed this special health insurance scheme for senior citizens for covering all the associated medical expenses incurred under certain pre-defined circumstances.
This health insurance plan is loaded with many attractive features including the cost of inpatient treatment at any hospital, domiciliary hospitalisation care costs along with 140+ day-care expenses. All the coverage is available in either a reimbursement facility or a cashless facility.
Eligibility Criteria for National Senior Citizen Mediclaim Policy
| Criteria | Details |
| Entry Age | The minimum age is 60 years and the maximum limit is 80 years |
| Sum Insured | INR 1 lakh to INR 10 lakh |
| Policy Term | 1-year |
| Renewability | Lifelong renewability |
Basic Features of National Senior Citizen Mediclaim Policy
1. Sub-limit
The scheme allows sub-limits under certain specific circumstances:
- For cataract-related treatment costs, a sub-limit of INR 10000 is followed
- For prostatic hyperplasia treatment which is benign or related treatments, a sub-limit of INR 20000 is maintained
- A maximum of 20% of the total insured sum is applicable under domiciliary hospital coverage
- Ambulance charges of INR 2,500 are the sub-limit
2. Co-payment
Under the following circumstances, co-payment is applicable:
- 10% co-payment is applied for pre-existing diabetes for the first two policy periods.
- 10% co-payment applies for pre-existing hypertension for the first-two policy periods.
- 25% co-payment is applicable for pre-existing hypertension and diabetes for the first two policy periods.
3. Pre-policy Medical Check-up
Pre-policy medical tests are not necessary for the ones who are insured under any plan offered by the National Insurance Company.
- The applicants who are not insured by any health insurance plan by the National Insurance Company need to undergo medical screening at their personal expenses.
- If the concerned health insurance company accepts the proposal, then 50% of these medical screening expenses are reimbursed.
- The medical reports must not be dated within 30 days of the policy proposal date.
4. Policy Renewal
You can ensure this health insurance policy renewal annually by punctual payment of the renewal premium. This premium must be paid within 30 days of the expiry of the plan.
Read more - The Importance of Health Insurance On-time Renewal
5. Waiting Period
For pre-existing diseases, the policyholder needs to serve a waiting period of 2 years and for specified illnesses/ailments, the waiting would be 4 years. However, the policy also comes with a 1 year waiting period of specific treatments like Benign ENT disorders, Tonsillectomy, Adenoidectomy, Mastoidectomy and Tympanoplasty.
Read more - Waiting Period Clause in Health Insurance
6. Initial Waiting Period
An initial waiting period of 30 days needs to be mandatorily served by every policyholder.
7. Loading
Up to 85 years of age, a 10% loading premium is applied and a 20% loading premium is applicable for those above 85 years of age.
Read more - What is Loading In Health Insurance Policies
8. Free-look Period
A free-look period of 15 days is applicable to offer them ground for cancellation in case of any dissatisfaction.
9. Policy Withdrawal
The plan can only be withdrawn by the company. The concerned policyholder is offered the opportunity to switch to any other similar plan
10. Critical Illness Survival Period
A critical illness survival period of 30 days needs to be served for claim settlement.
11. Number of Claims in a Policy Term
You can raise as many health insurance claims as you want but the sum insured should not be surpassed.
Benefits of National Senior Citizen Mediclaim Policy
- In case of hospitalisation, room rent charges of up to 1% of the total sum insured are offered. Per day ICU charge of 2% is induced.
- Domiciliary hospitalisation costs under special medical recommendation are covered except for any treatment for less than 3 days; pre-and-post-hospitalisation charges; medical treatments for certain ailments like bronchitis, chronic nephritis, asthma.
- In-patient hospitalisation facilities are offered in case of 24 or more continuous hours of hospitalisation.
- Pre-hospitalisation cover 30 days before hospitalisation, as well as post-hospitalisation for a period of 60 days after discharge, are covered.
- A waiting period of 2 years is applicable for pre-existing medical conditions. For certain ailments, the waiting period is 4 years.
- You can enjoy tax benefits under this scheme under Sec. 80D of IT Act, 1961.
Exclusions of National Senior Citizen Mediclaim Policy
- Expenses caused for treating conditions like HIV/AIDS
- An initial waiting period of 30 days for any ailment
- Self-inflicted injury by alcohol, drug, or others
- Venereal and sterile diseases
- Congenital anomaly treatment costs
- Any kind of vaccination
- Aesthetic or cosmetic treatment costs
- Hospitalisation for diagnosis
- Naturopathy and dental treatment
- Expenses incurred for tonics and vitamins unless prescribed by physicians
- Costs for contact lenses, spectacles, and hearing aids
Claim Notification Under National Senior Citizen Mediclaim Policy
In case of cashless claim notification for planned hospitalisation, the TPA must be informed at least 72 hours prior to hospitalisation. In case of emergency hospitalisation, they must be informed within 24 hours. The same rule applies to reimbursement claims too.
Documents Needed for Filing a Claim Under National Senior Citizen Mediclaim Policy
- Claim application form
- Original bills of the hospital, chemist, etc.
- Original receipts, discharge certificate, patient medical history, etc.
- Original prescription and investigation reports
- Diagnosis certificate from the attending physician
- Surgeon’s certificate in case of operation
| Claim Type | Time Limit |
| Reimbursement claim for pre-hospitalisation and hospitalisation | Within 15 days of discharge |
| Post hospitalisation reimbursement claim | Within 15 days after the completion of the post-hospitalisation tenure |
| Reimbursement of health check-up charges | Minimum 45 days before the expiry of the 4th policy period |
Conclusion
The above discussion sheds light on this senior citizen health insurance plan. You can utilise the digital health insurancepremium calculator for better management and understanding of your financial status. You can purchase this health insurance online. This is one of the most effective and important tools to cope with medical inflation for aged people. It has become more relevant, especially after the worldwide outbreak of Covid 19.
Read more - Health Insurance for Senior Citizens Offered by Government-owned Insurers
