Mediclaim: Overview, Types & Features of Mediclaim Policies

Living life to the fullest is mainly about maintaining a healthy lifestyle. A well-managed diet and staying active keep you in a good shape. While you should adopt these healthy practices, do not expect them to make you immune to health complications. Despite your best efforts, you cannot predict medical emergencies. They can occur when you least expect them because several factors influence health conditions. The best way to tackle such emergencies is to get insured to pay for unprecedented medical expenses. Refer to this guide to understand the mediclaim meaning and what it entails in detail. 

What is Mediclaim?

Mediclaim is a type of a health insurance policy that offers financial protection when you face a medical emergency. Under this health plan, you can claim for the hospitalisation costs incurred from illnesses, injuries, and accidents. You receive coverage for these illnesses, injuries, and accidents up to the specified sum insured. Shielding yourself this way allows you to get through unexpected expenses smoothly. 

Besides the base coverage, you also get other value-added features that protect your finances. As for convenience, insurers leverage digitisation to ensure everything is hassle free. Most insurers provide mediclaim information on their website, let you choose from various plan options, and enable you to buy a plan through a simple process. You also get a premium calculator to estimate the applicable cost and make an informed decision. 

Types of mediclaim policies in India

Various types of mediclaim policies available to meet your distinct healthcare needs are as follows:

Individual mediclaim policy

The coverage under this policy extends to a single person. Hence, only the policyholder is entitled to enjoy compensation for medical expenses. 

Family-floater plan

You can cover your entire family, including your spouse, children, and parents, under a single family floater plan. Thus, you can pay a single premium to cover the medical concerns of all family members conveniently. 

Critical illness mediclaim

Certain critical health conditions require testing, check-ups, and treatment for a long period. The examples of these conditions include cancer, multiple sclerosis, cardiomyopathy, heart problems, etc. They are specifically covered under the critical illness mediclaim policy. 

Group mediclaim

Employers generally purchase this mediclaim policy to protect their employees’ well-being. They are responsible for paying the insurance premium on the employees’ behalf. The coverage under such plans can extend to employees’ spouses, children, and parents. 

Senior citizen mediclaim policy

Age-related diseases require advanced treatments. Not all of them get covered under regular mediclaim plans. Hence, a senior citizen mediclaim policy is specifically designed for individuals with the age of 60 years and more. It comes with special provisions like high tax benefits. 

Salient features of a mediclaim policy

Here are some of the prominent features of a mediclaim that give you an insight into what it entails before buying the policy:

Lifetime renewability

As you get older, health complications increase. As a result, buying your desired coverage requires paying a higher premium than regular premium. You may also face denial for coverage if you have major health issues. With lifetime renewability, you can solve this problem by buying early and renewing your mediclaim policy, irrespective of your age.  

Range of expenses covered

All kinds of major expenses incurred upon hospitalisation get covered under mediclaim. These expenses can include consultation fees, medicines, room rent, diagnostic tests, follow-ups, etc. The exact coverage differs from insurer to insurer. You get an accurate understanding by studying the mediclaim information on your insurer’s websites. 

No claim bonus 

The insurance company rewards you for completing a claim-free year with a benefit called no claim bonus. You can use it either as a discount on the premium or a cumulative benefit to increase the coverage amount. Check with your insurer to know which type of no claim bonus is available. 

Convenient claim settlement 

Like the buying process, insurers ensure your claim filing process is smooth. You can inform the insurance company and fill out a simple form online to get through the formalities. After verification, your claim gets settled at the earliest through a cashless facility or reimbursement. 

Overseas coverage

You can choose a mediclaim policy that covers your medical expenses overseas. With this feature, you need not worry about the financial burden during medical emergencies, whether in India or abroad. Insurers may levy certain conditions on the same. You should check this in the mediclaim details. 

What is covered and not covered under a mediclaim policy?

When you go through the mediclaim details, it helps to learn about the coverage and exceptions in the policy. Doing so gives you clarity and prevents unnecessary surprises during claim settlement. The covered and non-covered expenses differ from insurer to insurer. Some typical inclusions and exclusions are listed below:

Inclusions

• Hospital costs

Expenses incurred during your hospital stay on medicines, tests, oxygen, emergency care, etc. form an integral part of mediclaim coverage. 

• Doctor’s fees

The step of getting hospitalised involves a doctor’s consultation and diagnosis. The fees they charge for this also come under the coverage in mediclaim. 

• Room rent 

Depending on your treatment, you may have to stay in the hospital for days. Mediclaim policy covers the rent for a room, whether it is a ward, private room, or intensive care unit. But the claim amount depends on the sub-limit. 

• Day care expenses

Some medical treatments do not require hospitalisation because a patient gets treated within 24 hours. Few examples of such treatments include cataract operation, radiotherapy, and dialysis. Certain types of mediclaim policies include them in coverage. 

• Pre-and-post hospitalisation expenses

The expenses you incur before 30 days of hospitalisation and 60 days post-discharge add to the entire treatment cost. These expenses include consultation, follow-ups, after-care, etc. Selective mediclaim policies cover them. 

Exclusions

• Dental treatments

Dental procedures are mostly planned and come under the arena of cosmetic surgery. Hence, most mediclaim plans exclude them from coverage. Some insurers may consider them if medically recommended. You can confirm this in the mediclaim information on their websites. 

• Addiction to drugs and alcohol

Any expenses incurred on treatment or medications for addiction to drugs and alcohol do not count as a medical emergency. They are not a result of any health complication. Thus, mediclaim policies exclude them. 

• Congenital conditions

Some medical conditions are congenital disabilities like cleft lip, down syndrome, and abnormal limbs. Since they do not occur during the policy period, they are not covered under mediclaim. 

• Suicide attempt

Any form of self-harm goes against the fundaments of getting a health insurance/mediclaim policy. Hence, insurers exempt it from coverage. 

• HIV/AIDS

HIV/AIDS is a health condition that most health insurance plans/mediclaim policies do not cover. However, you can buy a separate cover for treating it. 

Why should you care about mediclaim?

The inflating medical costs speak volumes about the importance of buying a mediclaim policy. Despite this, most people neglect it until it’s too late. You can avoid this and invest in it early to get the best coverage at a lower cost. Some other benefits making a mediclaim a worthwhile investment are:

Finances 

The premium you pay for a mediclaim policy may seem a hefty cost. But it saves you from substantial expenses incurred on medical treatments in the long run. Additionally, you can also adjust the insurance premium according to your affordability and coverage needs. 

Tax exception

Mediclaim policies let you enjoy tax exception on the premium paid under section 80D. Under this provision of the Income Tax Act, you can claim up to ₹25,000 if you are aged below 60 years. For senior citizens, the claim amount extends to ₹50,000. 

Savings protection

You build your savings for short and long-term financial goals. These goals may include retirement planning, capital appreciation, and higher education funding. With medical emergencies, such saved-up capital faces threat. You can prevent this with a medical policy/health insurance. 

Relief from financial stress

A medical crisis is hard to deal with. You go through emotional distress while trying to get treated immediately. In such situations, the last thing you want is to go through a financial dilemma. You get relieved of this burden thanks to your investment in a medical policy or health insurance. 

Simple buying terms

Buying a medical policy has become easier than ever today. Insurers leverage digitisation to make the buying process convenient for you. You find all the mediclaim details on the insurer’s official portal. You can go through the portal and complete the buying procedure within a few minutes. 

Difference between mediclaim and health insurance

Typically, most policyholders refer to mediclaim and health insurance interchangeably. However, there is a distinct difference between health insurance and mediclaim meaning. Go through the following aspects to understand this: 

Coverage

Mediclaim plan only assists with hospitalisation, accident-related treatments, and curing illnesses. Hence, mediclaim coverage is restrictive in nature. A health insurance policy is apt if you want comprehensive coverage. It covers pre- and post-hospitalisation charges, ambulance costs, daily cash allowance, etc. 

Add-ons

The coverage scope is restricted to the base cover in a mediclaim policy. Hence, it does not include riders. If you want to extend your coverage, a health insurance plan lets you do so through add-ons. You can choose additional covers for critical illness, maternity, room rent waiver, second medical opinion, etc. 

Sum assured

Under a mediclaim plan, the sum insured does not exceed ₹5 lakh. However, this amount goes up to ₹6 crores per year when you opt for a health insurance policy. The reason is the extensive coverage and range of complications like treating severe diseases as well as pre- and post-hospitalisation that can incur expenses beyond ₹5 lakh. 

Claim settlement

A mediclaim policy allows you to file claims until the sum assured gets exhausted, and you can make multiple claims. But it is not as simple with health insurance as it entails complex covers. The assured sum gets paid in lumpsum when claims are related to accidental disability or critical illness. However, typically, these claims get raised only once during a financial year. 

Hospitalisation condition

The fundamental mediclaim meaning pertains to compensating expenses related to hospitalisation. Hence, you must get hospitalised to avail of the mediclaim benefits successfully. This is not necessary in the case of health insurance. It also covers expenses for day care procedures, emergency procedures, domiciliary treatments, etc. 

Factors to remember while buying a mediclaim policy

Go through these important insurance terms in the mediclaim information section to attain clarity while buying the policy: 

Sum insured

The sum insured is the maximum coverage amount decided for compensating your medical expenses. You can adjust it based on your healthcare requirements. A higher sum insured results in an increased premium and vice versa. Consider this aspect while making the decision. 

Premium calculation

Insurers evaluate your profile to decide the premium amount. They look into your age, location, body mass index, pre-existing illnesses, medical history, location, etc. Evaluate the same to understand the insurance quote you can expect. 

Sub-limits

The hospitalisation expenses vary based on your preference. They are limited when you go for a minimum requirement and increase when you opt for premium facilities. Due to this, insurers set a cap on claim amounts for certain expenses known as sub-limits to protect their interests. 

Co-payment 

Under this clause, you must pay a portion of the expenses during the claim-settlement process. The insurers bear the rest of the burden. Understanding the same helps you plan your finances accordingly.  

Waiting period

If you get admitted for treatment of a pre-existing illness, you cannot raise a claim for compensation. Your insurance starts being effective after you undergo a waiting period ranging between one and four years for the pre-existing illness. 

How to buy a mediclaim policy online?

Due to digitisation, the insurance buying process has been simplified and completed seamlessly. The simple steps involved include:

1. Understand your insurance needs and finalise the right mediclaim policy.
2. Visit the insurance company’s official website. 
3. Under the mediclaim section, select the policy type you want. 
4. Go through the terms and click on the ‘Buy Policy’ option. 
5. Enter details like your name, gender, and location to get a premium quote. 
6. If you agree with the cost, continue filling in additional information for completing KYC formalities. 
7. Once done, you get redirected to a page to initiate payment. 
8. After successful payment processing, your mediclaim papers get sent to your email inbox. 

What is the claim settlement procedure in mediclaim?

Insurance companies settle claims in mediclaim policies in two ways: Reimbursement and Cashless Settlement. Let us understand how these methods work:

Reimbursement

In this claim procedure, you get hospitalised and pay for all the medical expenses. After getting through the medical emergency, you can submit the claim form and all the treatment-related documents. The insurer evaluates your information, and the amount gets reimbursed into your bank account if it is within the coverage terms. 

Cashless Settlement

To make dealing with claims easier, insurers tie up with network hospitals. You can raise a cashless claim if admitted to a hospital within the network. Doing so allows you to conveniently get through hospitalisation without struggling with bill payments. Insurers settle them directly with the hospital. The only thing left is furnishing your insurance card and/or claim reference number at the counter. 

Final note

Now that you know what is mediclaim, you can make an informed decision while buying a policy. Use this knowledge to compare offers online and choose the apt insurer that meets your healthcare needs. The comparison also helps you get an affordable premium quote. Another method of adjusting the insurance cost is knowing your coverage needs. Get covered only for what is essential and avoid overpaying. Also, choose the right policy that works in your favour. For instance, if you are the breadwinner in your family and seek health protection, consider a family floater plan for all members instead of buying separate individual mediclaim policies. 

Choosing suitable mediclaim is also about considering the insurers’ reputation. Several insurance companies have surfaced online after digital revolution. They may offer attractive quotes to increase the appeal. Instead of getting lured by such offers, go through the mediclaim information for clarity. Consider aspects like claim settlement ratio, customer support, and authenticity before opting in. Also, check if your chosen insurer has partnered with network hospitals around your area to avail of the cashless facility.