Mediclaim is an insurance product that reimburses the expenses you incur in the event of hospitalization or domiciliary care. It can either reimburse your expenses when you submit relevant bills or enable you to have an entirely cashless hospitalization where your insurer will directly deal with the hospital – letting you focus on treatment and healing.
The policy has to be renewed for continued benefits.
- Premiums – that are payable on Mediclaim policies differ between insurers but are based on certain criteria like an age of the proposer, geographical area of treatment, sum insured, the term of the plan, etc.
- Age – of insured persons can range from 5 years to 80 years, although age criteria and range insurable varies between companies.
- Family cover – You can provide Mediclaim cover for your entire family with the payment of one master premium. This may also make you eligible for discounts on your premium, depending on your provider.
- Overseas Mediclaim Policies – A large number of insurance companies offer Mediclaim policies that cover you in India and overseas, subject to certain predetermined conditions.
- Claims – are administered largely through Third Party Administrators (TPAs) these days, but a few insurers deal with claims in-house.
- Types – Mediclaim policies are available in a range of types, depending on the need and the category of those to be insured. You can get individual policies, group policies, senior citizen policies, critical illness policies and special maternity policies.
- Tax benefits – under Section 80D are available up to Rs.15,000 on mediclaim premiums for yourself, spouse and dependent children. An additional Rs.15,000 of tax exemption is available if you ensure your parents, and the amount goes up to Rs.20,000 if they are senior citizens.
How is Mediclaim Different from Health Insurance?
Insurance companies offer health insurance products under two broad categories – indemnity policies and benefit policies:
- Benefit policies are mostly traditional health insurance policies which pay out a pre-determined “sum insured” amount on the occurrence of an accident, or diagnosis of any of the illnesses, diseases, conditions, etc. that have been insured against. Traditional insurance policies work this way, offering you a financial benefit up-front and not necessarily requiring you to submit hospital bills, etc.
- Indemnity policies compensate or reimburse you for the expenses incurred during your hospitalization or domiciliary care, on the submission of necessary proofs, up to the limiting amount mentioned in the policy. Mediclaim is an example of such a product. Although with recent advancements, mediclaim enables cashless hospitalization facilities wherein the insurer pays the hospital directly.
The most important difference between mediclaim and health insurance is that mediclaim will only reimburse your expenditure, and not provide you with a large-sum financial benefit in case you are rendered unable to earn.
Types of Mediclaim Policies in India:
- Individual Mediclaim – where you basically insure yourself against the financial liabilities of hospitalization.
- Family Floater – where you can provide additional coverage for your entire family, and be tension-free in matters of hospital bills and related expenses.
- Group Mediclaim – where an employer or person in charge of a group of people wishes to add to their remuneration the benefits of cashless hospitalization and/or reimbursement on hospitalization expenses.
- Overseas Mediclaim – where all your hospitalization and related expenses are taken care of during your stay (or travel) outside India.
- Low-cost Mediclaim – is for the underprivileged masses. Employers of small-scale and medium-scale industries insure their employees and their dependents for as low as Rs. 1,600 per annum.
- Senior Citizen Mediclaim – while this type of mediclaim requires testing and/or special provisions, it’s a huge step forward for the industry as they can safely ensure senior citizens at competitive premium rates.
- Critical Illness Mediclaim – among the most expensive treatments in the field today are those incurred on treatment of critical illnesses. Critical Illness Mediclaim policies usually offer a higher claimable amount, and include some of (but are not strictly limited to) the following:
- Aorta graft surgery.
- Cancer.
- Coronary artery bypass surgery.
- First heart attack.
- Kidney failure.
- Major organ transplant.
- Multiple sclerosis.
- Paralysis.
- Stroke.
- Primary pulmonary arterial hypertension.
What does a Best Mediclaim Policy Cover?
Mediclaim policies offer excellent benefits and coverage for a wide range of expenses, depending on your insurance provider. Mediclaim policies in general offer the following benefits and cover:
- Hospital charges – all direct charges that you incur as a result of hospitalization like OT charges, medicines, blood, oxygen, diagnostic material, x-rays, chemotherapy, radiotherapy, pacemakers, donor expenses during organ transplants, etc.
- Day-care treatment – expenses towards specified technologically-advanced treatments where 24-hour hospitalization is not needed.
- Pre and post-hospitalization expenses – for a period of 30 days before and up to 60 days after hospitalization and may include assistance in availing emergency services like ambulance, etc.
- Hospital accommodation charges – in regular wards or in ICUs are fully reimbursed, or taken care of with the cashless hospitalization facility.
- Medical professional’s fees – like doctor’s fees, nurse’s fees, anesthetist’s charges, etc.
- Investigation charges.
What Do Mediclaim Policies not Cover?
Different providers have different exclusions in their policies, some may not even consider the standard exclusions and provide benefits anyway. Nevertheless, a standard Mediclaim policy would not cover you for treatment or expenses arising from or attributable to the following:
- All pre-existing diseases, medical conditions and injuries that are present before the policy comes into force.
- All diseases and medical conditions (unless otherwise specified in your policy document) that arise within the first 30 days of your policy commencement date.
- Injuries or medical conditions caused by war (whether it be declared or not), hostile foreign invasion or attack, war-like operations, etc.
- Plastic surgery and circumcision (which is not necessary as a treatment for illness or accident), cosmetic or aesthetic treatments of any kind.
- Cost of spectacles, hearing aids, contact lenses, etc.
- Dental treatment and surgery whether it is corrective, cosmetic or aesthetic – unless it arises due to an accident and requires hospitalization.
- Intentional self-injury and attempted suicide.
- Alcohol/drug abuse.
- STDs like HIV / AIDS, human T cell lymphotropic virus type III (HTLB III), lymphadenopathy-associated virus (LAV) or their variations.
- X-rays, laboratory tests and other expenses incurred not in direct relation to the treatment.
- Injury or disease arising from nuclear radiation or exposure to nuclear weapons and materials.
- Pregnancy, childbirth, miscarriage, abortions, cesarean section, etc. or any complication arising from these.
- Nautropathy related treatments.
Points to Consider When Buying a Mediclaim Policy:
To choose the right mediclaim policy, keep the following points in mind:
- Health insurance coverage: Selecting the right mediclaim policy is important so as to avoid ending up with insufficient health cover. Pick sufficient sum insured to cover all your medical expenses.
- Co-payment: A health insurance policy with a co-pay clause is one where the policyholder agrees to pay a part of the medical expense out of his or her pocket while the insurance company pays the rest. Co-pay can reduce the insurance premium of your mediclaim policy. It is a common feature in senior citizen health insurance policies.
- Treatment-specific limits: Insurer’s levy limits on certain medical treatments like cardiac treatments or cataract. Before purchasing the policy check for any treatment specific limits.
- Waiting period: Health insurance policies have an initial 30-day waiting period for all illnesses except in the case of an accident that leads to hospitalization. Pre-existing disease cover usually begins after a 4-year waiting period. During the waiting period, policy benefits can’t be availed. Therefore, it is important to check to wait for period clause of the policy.
- Network hospitals: Cashless hospitalization facility can be availed only at a network hospital of the insurance company. Check the list of network hospitals in your location.
- Maternity cover: Pregnancy-related medical expenses are usually not covered by regular health insurance policies. Therefore, check if your insurance providers offer maternity cover and what is including in the coverage.
- Exclusions: Read the policy document carefully, especially the exclusions of the policy. Exclusions usually include suicide attempts, dental treatments, self-inflicted injuries, alcohol or drug abuse, etc.
- Free-look period: Go through the terms and conditions of the policy during the free-look period, if you have any objections, you have the option to return the policy within the free-look period and get a refund on the premium paid after certain deductions.
Checklists Before Buying a Mediclaim Policy:
Here is a 10-point checklist before buying a mediclaim policy:
- Buy a health insurance policy before it’s too late: It is advisable to purchase a health insurance policy with a lifelong renewability option when you are young and in good health so that you may be covered when you need it the most. You can accumulate no-claim bonus with every claim-free renewal over the years. There is an age limit on purchasing a health insurance plan. Moreover, senior citizen health insurance plans can be restricting compared to regular health insurance plans.
- Assess who in your family needs health cover: In the case of a family insurance plan, the sum insured is shared by the entire family which is why it is important to assess who needs health cover and their health condition at the time of purchasing the policy. The insurance premium of a family floater plan depends on the age of the eldest member of the family. If there are members with a medical condition and are aged above 50 years, there can be certain time-bound exclusions in the policy.
- Keep a check on your health and lifestyle: There is an increase in lifestyle disease due to individual lifestyle choices and habits like smoking, drinking, and eating out often. Exercise regularly and keep a check on your diet. Avoid a sedentary lifestyle. It can protect you from contracting an illness.
- Determine whether you require an individual cover or a family floater plan: Though a family floater plan is cost-effective, having a high-risk family member as a part of the cover can lead to other members being left without any cover when they need it.
- Choose sum insured on a long-term perspective: When choosing the sum insured don’t consider just the current costs of healthcare. Healthcare costs keep increasing rapidly, therefore consider your insurance requirement on a long-term basis, and choose a sufficient sum insured.
- Sub-limit on room rent: Check if your chosen health insurance policy comes with a sub-limit on room rent. For instance, for a health insurance policy with a sum insured of Rs.2.5 lakh, you can stay in a room with a rent of Rs.2,500. Any additional cost on room rent has to be paid by the policyholder out of his or her pocket. The reason for setting a sub-limit is to reduce the liability of the insurer to the policyholder.
- Check for co-pay clause in your chosen policy: If you have an existing policy, review the insurance coverage and determine whether you require additional coverage. If you are dissatisfied with the current insurer, you can transfer your mediclaim policy to a new insurer at the time of renewal.
- Network hospitals of your insurer: Cashless facility can be availed only at one of the network hospitals of the insurer. The list of network hospitals can be found on the insurer’s website. Check for the network hospitals in your location.
- Opt for top-up plans: To get a high sum insured for a longer policy term, you can opt for a super top-up plan. For instance, you can choose a base cover of Rs.5 lakh and a super top-up cover of Rs.15 lakh. This can help you save on insurance premium. Ensure you purchase the super top-up plan along with the base policy tenure and same renewal dates.
- Review your existing policy: If you have an existing policy, review the insurance coverage and determine whether you require additional coverage. If you are dissatisfied with the current insurer, you can transfer your mediclaim policy to a new insurer at the time of renewal.