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Mediclaim Policy

Mediclaim policy is a part of health insurance policy that is designed to shield you against the ever-soaring medical expenses. A Mediclaim Policy offers the much-needed financial protection in case of an accidental hospitalisation or hospitalisation due to an illness, be it emergency or planned. You avail the policy benefits in exchange of a premium annually. This policy comes with a defined tenure, after which it needs to be renewed to avail the policy benefit.

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Mediclaim policy is a hospitalization benefit that is offered by both public and private sector general insurance companies in India. The mediclaim insurance policy takes care of expenses following hospitalization/domiciliary hospitalization in case of any of the following situations-

  • In case of sudden illness or surgery
  • In case of an accident
  • In case of any surgery during the policy tenure

Features and Benefits of Mediclaim Policy

Amid the increasing number of lifestyle diseases, hospitalization expenses and healthcare it is inevitable to buy a mediclaim policy almost inevitable. It offers a cushion in case of an emergency. At the same time, it offers numerous other benefits such as

  • A cost-effective way of availing healthcare services
  • Cashless hospitalization facility
  • Lowers the financial burden
  • Eliminates out-of-pocket expenses
  • Offers peace of mind
  • The insurance provider manages the hospitalization expenses
  • Both individual and family floater mediclaim policies are available
  • Tax benefits on the premium paid every year

Types of Mediclaim Policies

There are different types of mediclaim policies that are available. You can choose a mediclaim policy as per your needs and enjoy your peace of mind. Let’s have a look at the various types of mediclaim plans:

  • Individual Mediclaim Policy - An individual mediclaim policy offers health coverage to only the policyholder. Only one person can avail the medical insurance benefits against the premium paid. There are a number of health insurance companies that provide individual mediclaim plans in India.
  • Family Floater Mediclaim Policy - A family floater mediclaim policy provides coverage to an individual, which is extendible to other family members including parents, spouse, and children.
  • Senior Citizen Mediclaim Policy - Senior citizen health insurance plans are designed to cover hospitalization expenses incurred on the elderly people who have crossed the age of 60 years.
  • Critical Illness Mediclaim - Hospitalization expenses incurred on critical illnesses are quite exorbitant. This type of mediclaim policy covers life-threatening illnesses like kidney failure, cancer, cardiovascular diseases etc.

Comparison between Mediclaim Policy and Health Insurance

Mediclaim Policy Health Insurance
It reimburses your actual medical expenses It gives you a lump-sum amount on diagnosis of any of the pre-specified critical disease, irrespective of your medical expenditure
It has much wider scope than critical illness because it covers hospitalization and treatment towards accident It covers only certain diseases like heart attack, kidney failure, paralysis, etc.
The policy is taken to defray the hospitalization expenses incurred at the time of hospitalization It not only pays expenses of critical illness but also compensate for financial loss that may arise due to critical illness

Read in Detail: Mediclaim Insurance Vs Health Insurance

How does Mediclaim Policy work?

There are two types of claims available under Mediclaim policy-

Cashless Procedure:

  • Cashless is a mechanism wherein a patient is treated in a network hospital, then insurer settles either the part of the claim or the entire claim with the hospital. It means, a patient doesn’t need to pay a penny to the hospital for the treatment. There are certain procedures which you need to follow to ensure the smooth claim process.
  • At the first level, all empanelled hospitals will have an insurance desk in their premises. A policyholder has to obtain a pre-authorization form from this desk, which has to be dully filled with correct information because any missed detail will only delay the entire process. This filled form needs to be stamped by the hospital and the doctor and then it has to fax across Third Party Administrator (TPA) or the insurer. After carefully examining the form, the company will approve a certain sum and send a fax back to the hospital saying that ‘X’ amount has been sanctioned for the treatment.
  • Let us understand this procedure with an example. If the hospital has given a treatment cost of Rs 4 lakh, the insurer and TPA will rework and for instance, approve Rs 3 lakh for treatment. Now, they will inform the hospital that they will reimburse expenses up to Rs 3 lakh only under cashless and if the total cost would be more than this limit, they will look at it later. However, at the time of discharge, the total billing amount comes at Rs 3.60 lakh. In this case, the policyholder has two options. The first option is, he will send all discharge letters and final bill copy to the insurer and wait for the revert. No doubt, it will take time. The other option is, policyholder himself pays the remaining amount, which is Rs 40,000 in this case, and then he submits those original bill receipts to the policy provider to get reimbursement of Rs 40,000.

Get More Info On Cashless Mediclaim Policy


In the case of reimbursement, it is pivotal to inform your insurance company that a hospitalization has been taken place or likely to take place in a near future. Either you could that by sending an email or by making a call. To get reimbursement, you need to submit all payment receipts, including bills of those medicines which you have bought from outside chemist. You need to make sure that original discharge card, final bills and payment receipts should be in one place, so that they can be submitted to the insurance company to get reimbursement.

Mediclaim Policy Coverage

The coverage varies from one policy to another, but usually, the following expenses are covered:

  • Hospitalization charges - It covers all the all direct charges incurred during hospitalization such as OT charges, diagnostic procedures, blood, oxygen, medicines, chemotherapy, x-ray, radiotherapy, donor expenses, pacemakers etc.
  • Day-care Charges - Expenses incurred on specified technically -advanced treatments like cataract surgery etc. that do not require hospitalization for more than 24 hours.
  • Pre and post-hospitalization expenses - Expenses incurred on hospitalization for a period of 30 days before admission and up to 60 days after discharge including ambulance cover are reimbursed.
  • Hospital Room Charges - Charges of regular wards or Intensive-Care-Unit are fully recompensed, or taken care of with cashless hospitalization in the network hospitals.
  • Fees Charged by Medical Professionals - Compensation is provided for fees charged by the doctor, surgeon, nurse, anesthetist etc.

What is Not Covered in a Mediclaim Policy?

Every mediclaim policy has some limitations. Mentioned below are the circumstances that can deny you claim-

  • A mediclaim policy will not cover pre-existing ailments.
  • Any medical condition or critical illnesses that are diagnosed within 30 days of the policy commencement date are not covered. You can read the policy documents to know the details of the plan.
  • Specific ailments that are not covered in the plan
  • Expenses incurred on dental surgeries unless it requires hospitalization
  • Birth control and hormonal treatment
  • Complication during childbirth and ectopic pregnancies

Factors to Consider while Finalising a Mediclaim Policy

If you haven’t bought a mediclaim policy and are planning to apply for the one, then it is highly recommended to check below points to make sure that you buy best policy. These factors can also be used to compare different insurance plan options available in the market.

  • Individual and Family Floater:

In individual plan, each individual is insured for a specific amount, whereas, in family floater, the whole family is insured for a fixed sum assured. In case of family floater, when the primary person dies or reaches a specific age, the policy is closed even other members who are still younger can’t renew the policy. In Individual plan, the individual is insured on separate parameters. The attainment of specific age will not impact insurance coverage of other family members.

  • Sum Insured (the Coverage Amount):

While 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 opt for the sum insured of your loved ones also, you might want to take higher sum insured into consideration.

  • Co-payment Option:

Various mediclaim plans come with co-payment clause. The co-payment is usually a percentage sum that the insured has to bear while raising a claim before the insurance provider settles the rest. Such co-payments can range from 10% to 30% based on the insurance provider.

  • Exclusions:

Every mediclaim plan is tailor-made so as to cover medical risks of the policyholder. Nevertheless, there are a few exclusions, which are either covered after a certain term or not covered at all. Conditions taking place due to reasons such as HIV infection, drug or alcohol addiction, suicide attempt, congenital diseases, etc. are not covered under the mediclaim policy. However, expenses related to hysterectomy, removal of kidney stones, gall bladder surgeries, and maternity, etc. are covered after a certain waiting period.

  • Network Hospitals:

One of the most important benefits of choosing mediclaim policy is the ease of the cashless settlement of the expenses incurred during hospitalisation. Every insurance provider has network hospitals and while seeking hospitalisation in any of such hospitals, you can avail cashless treatment if the treatment/hospitalisation is within the coverage scope. This aids in getting financial relief at the most crucial and critical times. Therefore, you must check out the network hospitals near your area, which have tie-ups with the insurance provider you want to purchase the policy from.

  • Renewability Age:

Although, policy offers coverage for one year only, but in reality, it is a relationship between you and the insurance company. So, your health Insurance policy should cover as you age because it is tough to get insurance at that age. If your policy doesn’t provide you coverage at that point of time then buying such a policy will not give peace of mind.

  • Pre-Existing Disease:

This is relevant only if you have a pre-existing disease at the time of taking insurance plan. It also covers those diseases which might arise from a pre-existing disease. For example, if you have diabetes at the time of taking the plan and later develop heart problem, then even the heart problem will be considered as a pre-existing disease. Almost all insurance companies have a clause that states that a pre-existing disease will be covered only if the plan has been renewed for a certain number of years. A best mediclaim insurance plan covers pre-existing diseases as soon as possible.

Are you looking for a Mediclaim Policy? Let Us Help You!

In today’s fast paced life where everything can be done online from ordering dinner to attending college, is it any wonder that many people choose to buy mediclaim insurance online? Bridging the gap between insurers and insured, PolicyBazaar is a one stop platform to find top mediclaim policies. Your quest to find a good plan will come to an end at PolicyBazaar where after giving basic details, like name, annual income, occupation, etc; you will get free Mediclaim premium quotes of various policies, which can be compared at a click of the mouse. While you compare mediclaim insurance plans, always pay attention towards overall limits, depth of coverage and empanelled hospitals. Moreover, after selecting a policy, you can use our Mediclaim premium calculator to compute your premium and thus, you can plan your financial goals effectively. Make a proper comparison and instantly buy a best mediclaim policy at affordable rates.


Written By: PolicyBazaar - Updated: 23 October 2019

When can You Claim after buying policy


You are not allowed to claim for illness during the first 30 days of a new insurance plan. However if the policyholder needs hospitalization expenses in case he meets an accident in 30 days of the new policy it is payable.


How is Mediclaim Different from Health Insurance?


There are two broad categories of healthy insurance – Benefits Policies and Indemnity policies:
a.) Benefits Policies
It is mostly traditional health insurance policies where you can claim pre-determine “sum insured” amount in the event of accident or treatment of any illness, diseases, etc. It offers you financial benefits up-front not necessarily demand hospital bills, etc.
b.) Indemnity policies
This policy reimburses or compensates the expenses incurred in the treatment or domiciliary care. The pre-mentioned amount in the policy will be given to the policyholder or the nominee when the necessary documents are submitted to the insurance company. The most important difference between health insurance and mediclaim is that mediclaim will only reimburse your expenses, and not provide you with the financial benefit in case you are unable to earn.


How Many Types of Mediclaim Policies available in India


There are many types of medicliam policies available in Indian market, details are given below:
Family Floater
This policy ensures you to provide a safe and secure life for your entire family.
Individual Mediclaim
It basically insures you against the financial liabilities of hospitalization in the unfortunate event of accident or illness.
Group Medicliam
This policy allows the person in charge of a group of people who wishes to add the remuneration the benefits of cashless treatment or reimbursement on hospitalization expenses.


What does a Best Mediclaim Policy Cover?


It covers hospital charges that mean all the direct charges that incurred in the hospitalization like OT charges, medicines, oxygen, blood or any other test that falls under the treatment. It also covers day-care treatment, expenses of particular technologically advanced treatment. The pre and post hospitalization is covered for the period of 30 days before and up to 60 days after the discharge.


How do Claim the benefits of my Mediclaim Policy?


There are two ways by which you can claim the benefits of my mediclaim policy that are reimbursement and cashless claim.
Make sure you inform the insurer or the TPA about the policyholder’s hospitalization and when it happened. Along with the hospitalization expenses make sure you keep your strong eye on the expenditure to maintain a record. Reimbursement needs a full billing papers that will help the insurance company to count the total amount clearly.
Cashless Claim
If you want a cashless claim you will have to fill in the details in the form and submit the same to the company. They will provide you a cashless claim.


What does Mediclaim Policies not Cover?


The exclusion point varies in different insurance policies. The very common thing that every Mediclaim does not cover is treatment or expenses in case if the policyholder is not able to earn after the treatment. It only covers the treatment expenses.


How to Select the Right Mediclaim Policy?


Today it is very easy to choose your policy from the wide range of insurance plan available in the market; you can easily compare and buy Mediclaim on our website. There are plans which ensure the best cover and are affordable. So give a check and buy the best policy on our website.


What is the eligibility condition for Mediclaim?


A person between the age of 18 to 65 years are eligible for Mediclaim policy. Children under the age of 18 can be covered if both the parents are currently covered on the payment of required premium.


What do I need to do after I get hospitalized?


The first thing you need to do is immediately inform the TPA of this unfortunate event, along with the details of your policy, hospital and treatment you need, for example, policy number, the name of the hospital and the name of the treatment undertaken. This is the major step one need to take after he or she get hospitalized to get the claim.


What is Mediclaim?


It is an insurance product that covers the expenses that occur in the treatment at the hospital. It is supposed to reimburse your expenses when the relevant bills are submitted or helps you to have a cashless hospitalization where the policyholder will directly deal with the hospital. Basically, it helps you to focus on treatment and healing rather worrying about the financial need for the treatment. The premiums payable under mediclaim policies is different for a different policy, but there are certain criteria like an age of the proposer, sum insured, geographical area of treatment and term of the plan, etc. It includes tax benefits under section 80D.