Mediclaim Policy

• Cost-effective- A mediclaim policy is a cost-effective way of availing healthcare services without exhausting your savings.
• Cashless Treatment- Cashless hospitalization facility is available in all network hospitals of your insurance company, which eliminates any out-of-pocket expenses in case of a medical emergency.
• Eases Financial Stress– It lowers the financial burden on the policyholder and his/her family by offering monetary assistance during a medical emergency.
• Individual and Family Floater Cover- Both individual and family floater  policies are available in the market.
• Hospitalization Expenses- Mediclaim policies cover in-patient hospitalization expenses, such as OT expenses, doctor’s fees, nursing charges, medicine costs, etc. incurred due to an illness or accidental injury.
• Lifelong Renewability- A mediclaim policy can also offer a lifelong renewability option to the policyholder depending on the opted policy.
• Additional Benefits- It comes with several additional benefits, such as ICUs charges, room rent, etc.
• Tax Exemption Benefits- Tax benefits under section 80D can be availed on the policy premium that is paid every year.

• Individual Mediclaim Policy

  An individual mediclaim policy offers health insurance coverage to only the policyholder. Only one person can avail the medical insurance benefits against the premium paid under this type of policy. Several health insurance companies provide individual mediclaim plans in India.

• Family Floater Mediclaim Policy

  A family floater mediclaim policy provides coverage to the policyholder along with his/her family members, including parents, spouse, and children. Under this type of policy, a single sum insured amount is available to all the family members on a floater basis. 

• Senior Citizen Mediclaim Policy

  Senior citizen mediclaim policy is designed to cover hospitalization expenses incurred by elderly people who have crossed the age of 60 years. The senior citizen health insurance policy coverage are customized to cover the health needs of senior citizens.

• Hospital Room Charges

  Charges of a regular ward or intensive care unit are fully recompensed or taken care of by the insurance company with cashless hospitalization at network hospitals.

• Fees Charged by Medical Professionals

  Compensation is provided for fees charged by the doctor, surgeon, nurse, anaesthetist, etc. while admitted to the hospital.

• Expenses incurred on dental surgeries unless it requires hospitalization
• Birth control and hormonal treatment
• Complication during childbirth and ectopic pregnancies
• Suicide attempt
• Congenital anomaly
• Addiction to alcohol or drugs
• HIV AIDS

You can read the policy documents to know the complete list of exclusions.

2. Sum Insured (Coverage Amount):

Whilae choosing the coverage amount or the sum assured, it is recommended to take various factors, such as rate of inflation, surging healthcare cost, etc., into consideration. Moreover, if you’re living in any metropolitan city, the costs of hospitalisation will be way higher than in rural areas. Likewise, if you cover your loved ones also in the policy, you might want to opt for a higher sum insured.

3. Co-payment Option:

Various mediclaim plans come with a co-payment clause. Co-payment is usually a percentage of the claim amount that the insured has to bear while raising a claim before the insurance provider settles the remaining amount. The co-payment can range from 10% to 30% based on the insurance provider. Thus, check for any co-payment under your mediclaim policy before buying.

4. Exclusions:

There are a few medical expenses that are either covered after a certain time or not covered at all under a mediclaim policy. For instance, HIV infection, drug or alcohol addiction, etc. are not covered under the mediclaim policy, but specific diseases like removal of kidney stones, gall bladder surgeries, etc. are covered after a certain waiting period. You must check the exclusions carefully before buying the policy.

5. Network Hospitals:

One of the most important benefits of choosing a mediclaim policy is the ease of the cashless settlement of hospitalization expenses at network hospitals. Every insurance provider has network hospitals where cashless hospitalisation can be availed. Therefore, you must check the network hospitals list of the insurance company near your area before you purchase the policy.

6. Renewability Age:

Some policies come with a lifetime renewability option allowing you to renew your policy irrespective of your age. This is essential for older people because it is tough to get insurance at that age. Therefore, you must check the renewability option of your policy before buying a mediclaim policy.

7. Pre-existing Disease:

Almost all insurance companies cover pre-existing diseases after a waiting period. While buying a mediclaim policy, you must check the pre-existing waiting period as the best mediclaim insurance plan will cover pre-existing diseases as soon as possible.

• Visit an empanelled hospital of your insurance company to receive the treatment
• Obtain a pre-authorization form from the insurance desk at the hospital.
• Duly fill the form with correct information and get it stamped by the hospital
• The hospital will send the form to the Third Party Administrator (TPA) or the insurer for approval.
• After carefully examining the form, the company will approve the treatment and send a fax back to the hospital stating the amount covered by them.
• Get treated and sign all documents during discharge
• Your insurer will pay the hospital bill amount.

Reimbursement Claim Procedure:

In the case of a reimbursement claim, it is important to inform your insurance company that hospitalization has taken place or is likely to take place soon. You can do so by sending an email or calling the customer service of your insurance provider.

Once you have received the treatment, collect all the medical documents from the hospital. To get a reimbursement, you need to submit all hospital bills and payment receipts, including medicine bills to your insurer along with the original discharge card and claim form. The insurance company will review your claim and will pay the reimbursement amount after claim approval.

• Address proof, such as driving license, passport, Aadhaar card, etc.
• Passport-size photograph
• Pre-policy medical test reports