Mediclaim Policy

Studies reveal that in spite of growing inflation rates clubbed with upsurge in healthcare costs, 70% of Indians are yet to opt for any sort of insurance cover protecting them against hospitalization expenses. It’s shocking to know that in a fast developing country like India, people are still being ignorant about the need to plan for a suitable arrangement to tackle any financial emergencies arising out of an accident or sudden illnesses.

What is Mediclaim Policy

The best and most economical way of being prepared for medical emergencies and protecting your savings is through a mediclaim insurance policy. It takes care of medical expenses following hospitalisation on illness or accident or even for any surgery required. The bills are taken care through either cashless treatment facility or reimbursement mode offered by the insurance company.

Mediclaim insurance policies reimburse your expenses on submission of relevant proofs like medical bills. Alternatively, it can make you eligible for an entirely cashless hospitalization where your insurer acts as the intermediary between your insurance company and the concerned hospital. You can claim your insurance with the insurance company to assess your eligibility, while you focus on your medication and recovery.

So, why is it important to invest in a mediclaim policy? The answer is simple – to safeguard your own financial well-being.

Why Mediclaim Policy

Mediclaim policy comes to your rescue in case you are hospitalized due to an accident or any ailment. It covers you for nursing, lodging and treatment costs up to the coverage amount that you choose while buying the policy. Most mediclaim policies also cover the treatment sought before and after hospitalization, related to the reason or ailment you were hospitalized for. This time frame depends on the insurers and typically ranges from 30 to 60 days before hospitalization and between 60 and 120 days after hospitalization.

The rapidly increasing cost of medical and healthcare, one of the reasons being rising inflation rates, emphasises on the importance of a mediclaim policy. Another reason that is making healthcare increasingly expensive is the growing rate of lifestyle-driven health issues. Sudden health emergencies are sure to leave a hole in your pocket, unless you prepare for it well in advance. A mediclaim insurance policy offers a lump sum health cover, which is the sum insured, when you need it the most. Mediclaim policies in India are available for a specific tenure as offered by insurance companies. These policies can be renewed to avail continued benefits.

In simple terms, mediclaim policy comes to your rescue in case you are hospitalized due to an accident or any ailment. It covers you for nursing, lodging and treatment costs up to the coverage amount you choose while buying the policy. Most mediclaim policies also cover the treatment sought before and after hospitalization related to the reason/ailment you were hospitalized for. This time frame depends on the insurers and typically ranges between 30 days before and 60-120 days after hospitalization.

Features & Benefits of Mediclaim Policy

Here are some of the salient features and benefits of a mediclaim policy:

  • Suitable for any individual between the age of 91 days to 65 years

  • Offers the flexibility to either opt for self or for the entire family

  • Covers pre-existing medical conditions after a waiting period of 2- 4 years

  • Get higher cover at affordable premiums

  • Offers the benefit of a high sum insured of as much as Rs. 50 lakhs and even more.

  • Can be ported to different insurer at the time of renewal

  • The most reasonable yet adequate medical assistance

  • Gives you and your family a complete health cover, proving to be an effective protection option

  • Includes cashless hospitalization to ensure that you don't have any out-of-pocket medical expenses

  • Easy online buying process from the comfort of your home

  • Enables you to avail tax deductions on premiums paid under Section 80D of the Income Tax Act, 1961

  • Can be renewed annually. Some insurers offer longer duration policies with renewals due every 2 or 3 years

Difference Between Mediclaim Policy and Health Insurance

Read About Difference Between Mediclaim Policy and Health Insurance Policy

CriteriaMediclaim PolicyHealth Insurance
FeaturesThis varies from one insurance provider to anotherThe features of a health insurance plan of a specific sum insured are more or less the same across insurers
CoverageHospitalization, accident related expenses, pre-decided diseasesComplete comprehensive cover which includes pre/post hospitalization, medical treatment expenses, accidents, loss of income
EligibilityEvery IndividualEvery Individual
Types of PoliciesIndividual Mediclaim Family-Floater Individual Health Family-Floater, Critical Illness, Cancer Insurance, Accidental Death Cover
Sub-LimitsSubject to the sum insured and room rentSubject to the sum insured and room rent
Sum AssuredDoes not exceed ₹5 lakhsDoes not exceed ₹6 crore per year
Co-payment10-30%, Depends on the policy issued10-30%, Depends on the policy issued
Waiting Period30 days from the date of policy commencement. Does not cover pre-existing diseases.30 days from the dte of policy commencement, 2-4 years for pre-existing diseases.
Network HospitalsPAN IndiaPAN India
Add-onsNoneRider Options such as Accidental Death Cover, Critical Illness Cover, Maternity cover, Disability Cover, etc
Free-look periodNone15-30 days from the date of policy purchase
Cashless ProcedureYes, across listed network hospitalsYes, across listed network hospitals
ClaimsOnline as well as Offline. Can be claimed until the sum assured is exhausted.Online as well as Offline. The sum assured is paid in a lump sum upon diagnosis of an illness or accident.
Renewability Age65-75 years65-75 years or lifetime

Types of Mediclaim Policies in India

Types of mediclaim policies can be broadly classified under two categories:

Individual Mediclaim Plan – Only the policyholder is insured against the financial liabilities of hospitalization.

Family Flotar Plan – Offers financial cover for your entire family that covers them against hospitalization, medical expenses and other health related expenditures.

Comparison Between Mediclaim Policy and Health Insurance

The following are the differences between a Health Insurance and Mediclaim Policy:

Type of cover: Health insurance policies are comprehensive, that is, it not only covers for your hospitalization expenses, but also includes pre and post-hospitalization expenses. On the other hand, mediclaim policies cover hospitalization expenses towards an accident or certain critical illnesses on certain terms and conditions, as specified in the policy document of insurance companies.

Critical Illness benefits: Health insurance plans provide covers on critical illnesses, as an inbuilt rider or add-on rider, on more than 30+ diseases, as specified in their policy documents. Some of the critical illnesses usually covered are:

  • Cancer

  • Stroke

  • First heart attack

  • Aorta graft surgery

  • Bypass surgery

  • Primary pulmonary arterial hypertension

  • Kidney failure

  • Major organ transplant

  • Multiple sclerosis

  • Paralysis

In contrast, mediclaim policies do not cover critical illness and other hospitalization expenses. Also, the types of critical illness that will be covered solely depend on the discretion of your insurance company.

Compare and Buy Mediclaim Policies Online

The Family Floater plan is highly recommended because it covers hospital expenditures for all your family members who have been included in the policy document. It includes spouse, parents and children. Opting for individual health insurance policies for every family member would require you to pay premium for each one of them separately. As opposed to this, a Family Floater will cover your entire family on the payment of one premium, proving to be a reasonable yet effective investment.

However, you need to keep in mind that a mediclaim cannot be considered to be an effective substitute for a health insurance policy. This is because a mediclaim reimburses hospital and other related expenditures. Therefore, it is best to look for a health plan that offers the right combination of features and benefits, along with simplified claim settlement and cost-effective premium payments.

How Are the Premiums Determined?

Insurance companies consider a lot of factors while determining the premiums for the mediclaim policy. Age, sum insured, geographical location, any pre-existing medical condition, number of members to be insured, the extent of coverage, etc. are some of them. While the guidelines are set by IRDAI, health insurance companies take the final decision regarding premium calculation on the basis of your needs and requirements. The more comprehensive your requirements are, the higher will be the premiums to be shelled out.

What is Mediclaim Policy Premium Calculator

How is mediclaim premium calculated?

Insurance companies have their own unique list of parameters that they consider while calculating premium. Here are some parameters that are generally considered by all insurance companies.

  • Age of the insured member
  • Sum Insured opted
  • Health history
  • Marketing expenses
  • Risk rating
  • Rate of morbidity
  • Medical underwriting

What is ‘premium’ in insurance?

Premium is the amount that the policyholder pays towards the insurance policy to become eligible for its benefits, as per the policy document.

Which are the best mediclaim policies in India?

Below are some of the best mediclaim policies in India:

  • Apollo Munich Optima Restore
  • Religare Care NCB Super Premium
  • Star Family Health Optima
  • Max Bupa Health Companion Individual
  • ManipalCigna ProHealth Plus
  • HDFC ERGO Health Suraksha Gold Regain
  • Royal Sundaram Lifeline Supreme
  • Aditya Birla Active Assure Diamond Plan
  • Star Senior Citizen Red Carpet Health Insurance Policy

What is the difference between health insurance and mediclaim?

  • Coverage: Mediclaim policies offer coverage only for hospitalization, accident-related treatment and pre-decided diseases for a pre-specified limit. In contrast, health insurance specializes in comprehensive coverages against hospitalization charges, pre and post hospitalization charges, emergency ambulance charges, etc.

  • Add-on riders: Mediclaim policies generally do not have add-on riders, while health insurance policies often include riders like critical illness coverage, accidental disability coverage, personal accident coverage, maternity coverage, etc.

  • Customization: Mediclaim policies cannot be customized as per the preference of policyholders. On the other hand, benefits like sum insured, policy duration, etc. can be charged as per the flexible options offered by the health insurance plan.

  • Claims: Claims against a mediclaim policy cannot usually be made until the insured person is hospitalized for the specified illnesses or diseases. In contrast, claims can be made against any expense incurred towards benefits like domiciliary treatment, annual health check-ups covered by the health insurance plan.

What Does A Mediclaim Policy Cover?

Benefits covered by a mediclaim may vary depending on the insurance company. These are the common benefits covered by mediclaim policies:

  • Hospital expenses – Expenses incurred due to hospitalization like medicines, oxygen, blood, OT charges, medical tests and diagnosis, chemotherapy, radiotherapy, organ transplantation, etc.

  • Hospital accommodation expenses – Expenditures towards ICUs are either addressed through cashless hospitalisation feature or are reimbursed by the company.

  • Day-care hospitalization – Expenditures towards tech-driven medical treatments that do not involve 24-hour hospitalization.

  • Pre and post-hospitalization expenses – Expenses incurred for up to 30-60 days before and till 60-120 days after hospitalization. It may also include medical assistance for emergency services like ambulance, etc.

  • Charges for medical experts – The fees for medical professionals involved during hospitalization like doctor, nurse, etc. are also provided by mediclaim policies.

  • Investigation charges

What's Not Covered in Mediclaim Policy?

While your mediclaim insurance will cover most expenses related to hospitalization and related costs, there are certain exclusions that are NOT covered in the policy. The list of what's not covered forms an integral part of the policy document and should be referred for more exhaustive information. Below are a few of the aspects that are not covered in most mediclaim policies.

  • Non-medical expenses like administrative charges, service charges, toiletries, diapers, syringes, etc.
  • Diseases/ailments contracted within a specific time from the policy purchase
  • Any dental treatment except in case of an accident
  • Sexually Transmitted Diseases and HIV
  • Cosmetic surgery, circumcision or plastic surgery
  • Vaccinations
  • Medical condition resulting from the addiction of alcohol, smoking, drug abuse, etc.
  • Health conditions arising out of war, nuclear weapon, etc.

What Should You Consider While Buying Mediclaim Policy?

Investing in mediclaim is a great decision. Consider all the factors involved and accordingly choose the right policy. Below are some of the aspects you need to keep an eye on before purchasing the policy:

  • Sum insured (coverage amount): While choosing the sum insured or the coverage amount, it’s advised to consider factors like rising healthcare costs, rate of inflation, etc. to choose the right amount. Also, if you are living in one of the metro cities, your cost of hospitalization will be higher compared to rural areas. Similarly, if you are opting for the coverage of your dependants too, you might want to consider higher sum insured.

  • Individual or Family Floater: This decision entirely depends on you. If you are unmarried and looking to cover only yourself then you can opt for the individual policy. However, if you choose to cover your entire family including your parents then selecting a family floater plan is the ideal choice. Family floater plans are also a bit easier on pocket compared to individual policies bought for each family member due to the discounts offered by the insurance companies.

  • Sub-limit on Room Rent: Most mediclaim plans are tailor-made with room rent sub-limit. These limits might vary depending on the insurance companies. To make it simpler, let’s explain with an illustration. Mr. Kulkarni bought a plan that had room rent sub-limit as 1% of the sum insured. He had chosen the coverage for Rs. 2 Lakh. That means, every time Mr. Kulkarni wants to claim hospitalization on his mediclaim, the insurance company will compensate his expenses limited to the room rent of 1% of his sum insured i.e. Rs. 2,000 per day. The entire calculation of his claim disbursement will be carried out as per his room rent limit even if he opts for a room higher than the limit of Rs. 2,000. Hence, it’s wise to choose the policy with proper room rent limit to avoid any rude shocks during claim settlement.

  • Co-payment: Many mediclaim policies are in-built with co-payment clause. Co-payment is basically a percentage amount that the policy holder needs to bear when the claim is raised before the insurance company settles the rest. These co-payments can range anywhere between 10% and 30% depending on the insurance company. For example: If you have opted for a mediclaim with 20% co-payment, whenever you raise a claim, you’ll have to bear the first 20% of the total claim amount and the rest will be compensated by the insurance company as per the terms and conditions of the policy. Some insurance companies also offer to cover the risks related to pre-existing diseases with higher co-payments.

  • Exclusions: Every mediclaim policy is designed to cover your medical risks. However, there are certain exclusions that are either not covered or covered after a specific term. Conditions arising out of a suicide attempt, HIV infection, congenital diseases, addiction to alcohol or drugs, etc. are not covered by any policy whereas expenses related to maternity, hysterectomy, gall bladder surgeries, kidney stones removal, etc. are covered after a specific waiting period. Most insurance companies cover the risks related to any pre-existing diseases only after 3-4 years. Details of these exclusions are mentioned in the policy wordings of the plan and one should definitely go through the same before finalizing to buy.

  • Hospital Network: One of the biggest benefits of opting for a mediclaim policy is the convenience of cashless settlement of hospitalization expenses. Every insurance company has a network of hospitals and when you seek hospitalization in any of these hospitals, you are entitled for a cashless treatment if the hospitalization/treatment is within the scope of coverage. This works out to be a great financial relief at most crucial times. Hence, check out and be aware of the hospitals in your area that is in tie-up with the insurance company you wish to buy the plan from.

  • Reputation of the Insurance Company: Last but not the least, it’s always wise to check the credibility and market standing of the insurance company you wish to buy the mediclaim from. Apart from this, a little study of their claim settlement ratio will also prove to be useful while making the final decision.

Who Should Buy Mediclaim Policy?

The sky-rocketing hospitalization and related healthcare costs might burn a hole in your pockets. It proves to be even more challenging when the expenses arise from unforeseen circumstances like hospitalization due to accidents and critical illnesses. Mediclaim policies serve as financial security, enabling individuals to be prepared for all eventualities. Considering the extensive range of benefits that you reap on these policies as compared to the reasonable premium payments, mediclaim policies are a smart investment option. Along with the financial cushion that it guarantees, the peace of mind that it offers makes it totally worth it.

Well, the answer is simple. Anyone who cannot possibly afford those sky rocketing hospitalization and related healthcare costs should definitely invest in a good mediclaim insurance. Considering the premiums you pay each year, the benefits you reap are much valuable. Along with a financial cushion to reckon, the peace of mind it offers makes it totally worth.

Documents Required to Buy a Mediclaim Policy

  • KYC - Proof of ID and Address.
  • Age Proof.
  • Medical Check-up/Report if required.
  • Passport-sized photograph

How to Claim on the Mediclaim Policy?

The claim process of a mediclaim policy has become increasingly more streamlined and quick, owing to the integration of advanced technology. The settlement process follows either of these two methods – cash reimbursement or cashless claims.

  • Reimbursement:

    If you opt for the reimbursement option during claim settlement, this is the process that is usually followed:

    • Inform your insurance company in the event of hospitalization in one of their network hospitals, as mentioned in their policy document. Insurance companies need to follow specific terms and conditions while reimbursement of hospital claims and would not approve of your request for claim settlement until the medical situation is aligned to these terms and conditions.

    • Closely monitor and keep a tab on the hospital and other related medical expenses incurred, on which you are eligible for claiming reimbursements. Mediclaims usually cover for basic hospital facilities in terms of room rent, bed, etc. You will not be eligible for higher claims if you avail luxury and personal comfort facilities. Insurance companies minutely scrutinize the facilities availed against the medical bills submitted by you, before reimbursing your claims. Expenses incurred for personal comfort are usually not considered during the claim settlement process.

    • You have to initiate a separate claim settlement process in case a new health concern arises. For instance, if you had initiated a claim settlement for the expenses incurred for medical tests for a heart disease and then you injure a hand, you have to sought another approval for this.

    • Take care to ensure that you fill up the claim form with accurate details, without suppression or misrepresentation of facts. Present the relevant medical reports and bills to support your claims, without which your claim will not be approved. Once your insurer has scrutinised the form and all the proofs of expenses are submitted by you, the claim will be reimbursed, if approved. This process usually takes around 15 to 25 business days.

    • There may be instances when insurance companies refuse to honour claims without a sound explanation. Ask for the reason and a detailed clarification for your claim getting disapproved, so that you are convinced of it. Otherwise, you can escalate the issue at a consumer form or even proceed with legal action.

  • Cashless Facilities

    • Cashless claims: To initiate this process, you have to fill up the Preauthorization Request Form and submit it to your insurance company through the network hospital.

    • Cashless planned hospitalization: If your hospitalization is pre-planned, it is necessary for you to submit the completed Preauthorization Request Form at least 72 hours before your hospitalization. This enables the insurer to ensure a seamless and hassle-free claim settlement.

    • Cashless emergency hospitalization: In case of an emergency hospitalization arising due to an accident or critical illness, you are usually expected to present your mediclaim ID at the network hospital to enable admission to the hospital. Post that, you need to submit the completed Preauthorization Request Form within 4 hours to initiate the claim settlement process. This implies that it is mandatory for you to keep your mediclaim ID handy with you always.

Documents Required to make a Claim

  • Claim Form/Pre-authorization Request Form
  • Attending physician's statement
  • Attested copies of all medical records
  • NEFT mandate form

    For a Death Claim:

  • Original policy documents
  • Original/attested copy of death certificate issued by local municipal authority
  • Death claim application form (Form A)
  • NEFT mandate form attested by bank authorities along with a cancelled cheque or bank account passbook
  • Nominee's photo identity proof such as copy of Passport, PAN card, Voter identity card, Aadhar (UID) card, etc.

    Medical Natural Death:

  • Attending physician's statement (Form 'C')
  • Medical records (admission notes, discharge/death summary, test reports, etc.)

    Accidental Unnatural Death:

  • Copy of the First Information Report (FIR) or Panchanama/Police complaint

  • Copy of Post Mortem report (PMR)/Autopsy and Viscera report

  • Copy of the Final Police Investigation report (FPIR)/Charge sheet

How Can Coverfox Help You Choose the Right Mediclaim Policy?

Here’s how Coverfox simplifies the process of selecting a suitable mediclaim policy.

  • Our online platform offers a comparative analysis of various mediclaim policies, offered by different insurance companies, which are aligned with your requirements. This ensures a convenient and hassle-free application process.

  • We offer expert and unbiased advice for assisting you with the right decision, as per your needs.

  • Coverfox is equipped with a dedicated customer service unit to assist you with all your pre and post-sales queries, including expert claims handling.

  • The process involves minimal paperwork to ensure quick and seamless buying experience.

  • Convenient & Hassle-free application process clubbed with online platform for comparison and choosing the right plan.

  • Expert & Unbiased Advice for assisting you with the right decision as per your requirements.

  • Dedicated Customer Service Unit to tackle all your post-sales queries including expert claims handling.

  • Minimal Paperwork to ensure hassle free and pleasurable buying experience.

How Does Mediclaim Policy Work?

You can avail the cashless benefits of a mediclaim policy only in the network of hospitals that is mentioned in your policy document. Undertake a thorough check of the network hospitals in your policy document and go through the websites of the insurance company and its network of hospitals, before making a final choice. This greatly reduces the scope for claim rejections later.

You may not be eligible to utilise the cashless benefits of your policy in any hospital other than those enlisted in your policy document. Therefore, before you make a claim against your mediclaim policy, ensure the expenses have been incurred in a hospital or chain of hospital that is a part of the network of your insurance company. You will mostly be able to avail the reimbursement facility at a recognized hospital of your insurer.

Getting admitted in a hospital that is not a part of the network of hospitals of your insurance company or an unrecognized hospital may reduce your chances of being eligible for claiming your settlement on hospital and other related expenses, but does not completely disqualify you from it. You may not be able to able avail cashless facilities, but you might be eligible for reimbursements from your insurance company. However, you have to be consistent with the premium payments on your mediclaim policy, keep the policy active and strictly follow the terms and conditions to avoid claim rejections.

After you have initiated a claim settlement on hospitalization, your insurer has to approve your request for cashless hospitalization. This process is referred to as authorization. It can take up to 24-72 hours for your insurance company to verify and approve your claim. Pre-planned hospitalization due to medical conditions and health concerns like surgeries will require pre-authorization before you get hospitalized. For emergency hospitalizations, prior authorization is not needed and would not get your claim rejected.

3 Checks Before Buying a Mediclaim Policy

Here are three things that you have to consider while buying an effective mediclaim plan that meets your unique needs.

Sum Insured, Features and Benefits

Choose a sum insured which takes care of the growing inflation in the medical sector and at the same time is economical and within your budget. An ideal plan must have features like coverage for a vast number of illnesses, procedures, etc. It should be free of room rent limits, co-payments and sub-limits. The plan should also have life-time renewals because it is the old age when health insurance is needed the most. Also take into consideration the waiting period for the coverage of any pre-existing illnesses, the lower the waiting period, the better it is. You must also read the exclusions carefully so that you do not get a rude shock in the time of need.

Incurred Claim Ratio

Incurred Claim ratio refers to the percentage of total claims made that were approved by an insurance company. This ratio is determined on the basis of factors like age of the business portfolio, business mix, etc. As this data and figures are not directly divulged to customers, it becomes difficult for buyers of mediclaim policies to understand how this ratio is finalized. Industry experts report that the incurred claim ratio for group mediclaim policies is higher than individual policies. An incurred claim ratio of at least 85% is considered to be an indicator of an effective mediclaim policy.

The incurred claim ratio is the total claims settled by an insurance company as compared to the premium that it had collected in a particular year. Check for the latest ‘Handbook of Indian Insurance Statistics’ to become aware of the current incurred claim ration of insurers, so that you can take a well-informed decision.

Network of hospitals

Ensure that the mediclaim enlists a few hospitals that you usually visit, are accessible to you, have the standard medical facilities, etc. For instance, if you would prefer cashless payments over reimbursements, ensure that the mediclaim that you select includes some network hospitalization that will offer you this facility in the event of hospitalization.

FAQs on Mediclaim Policy

How to choose a Best Mediclaim Policy?

You need to keep the following parameters in mind while selecting a suitable mediclaim policy:

  • Premiums – The payments made towards Mediclaim policies differ between insurance companies, based on various parameters like age of the applicant, location, policy tenure, sum insured on maturity of the policy tenure, etc.

  • Age – Suitable for individuals right from the age of 91 days to 65 years, though the terms and conditions regarding age vary between insurance companies.

  • Cover for family – The unique option of one master premium enables you to ensure mediclaim for your entire family. Not just that, such a facility often makes you eligible for additional benefits and discounts on premium, based on the insurance company and policy you have opted for.

  • Overseas mediclaim policies – Some mediclaim policies also cover you for emergencies that might occur when you are abroad, based on certain terms and conditions.

  • Claims – While some insurance companies channel their claims through Third Party Administrators (TPAs), some others process claims in-house.

  • Types – There are a wide range of mediclaim policies offered, which we will discuss later in the article.

  • Tax benefits – Mediclaim insurance premium are eligible for tax deduction under Section 80D of the Income Tax Act, 1961, Premiums up to Rs.25,000 on mediclaim premiums for self, spouse and dependent children. An additional tax exemption of up to Rs.25,000 is applicable on insuring parents and extends to up to Rs.50,000 for parents who are senior citizens.

What are the things to look for while choosing a health insurance plan?

While choosing a health insurance policy there are a few things which you should be ready with are:

  • Number of members and relations to be covered- Because this will be the basis of buying policy.

  • Type of coverage – Individual, Family floater or group.

  • Sum insured or coverage amount – Ensure that you consider future expenses too.

  • Room rent – Check for the capping amount or criteria defined if applicable.

  • Sub-limits or co-pay applicable – Check for the sub-limits applicable for some specific list of ailments or package treatments. Also check if the plan has co-pay feature.

  • Network hospital list – Check for the list of network hospitals and try buying a policy which covers your regular hospital.

  • Policy wording – Most important thing to check before buying a policy is the policy wording. In case you are not sure about certain term or condition you can always contact the insurer for clarification.

I am already having health insurance and want to increase sum insured, what should I do.

If you already have a health insurance policy, you can increase sum insured at the time of renewal.

When we buy a health insurance policy from your website, will we get a cashless card?


Is maternity covered in health insurance policies?

No. As health insurance policy is designed to cover unforeseen medical expenses a normal health insurance policy does not cover maternity expenses. Coverage for maternity expenses is one of the additional features offered by some of the health insurance plans at a higher premium and waiting period. To know more about maternity health insurance.

Which mediclaim policy covers pregnancy in India?

Some mediclaim policies that cover pregnancy in India are:

  • Star Wedding Gift

  • Max Bupa Heartbeat Plan

  • Oriental Insurance Universal Health Insurance Scheme

  • Apollo Munich Easy Health Individual Insurance Plan

Can I cancel my mediclaim policy and if yes will I get my premium back?

Yes you can cancel a policy after you buy it. A free look period of 15 days is provided to you after buying a policy to understand the terms and conditions. In case there is any objectionable clause, you can cancel the policy and get a refund. Stamp duty, expenses on medical check-up and proportionate risk premium (the number of days that the insurance company was at a risk of bearing your health expenses) would be calculated while the premium amount is refunded. Refer the policy termination or policy cancellation section in your policy wording to know the amount that would be refunded.

Note: For the refund to happen there should be no claim during the policy period.

Can a person have more than one Health policy?


Enlist some of the important exclusions under Mediclaim policy.

Here are some expenses that mediclaim policies do not cover:

  • Non-medical expenses like administrative charges, service charges, toiletries, diapers, syringes, etc.

  • Diseases/ailments contracted within a specific time from the policy purchase

  • Any dental treatment, except those caused due to an accident

  • Sexually Transmitted Diseases and HIV

  • Cosmetic surgery, circumcision or plastic surgery

  • Vaccinations

  • Medical condition resulting from the addiction of alcohol, smoking, drug abuse, etc.

  • Health conditions arising out of war, nuclear weapon, etc.

What are first year/ second year exclusions?

  • The first or second year exclusions include list of diseases or ailments which have a waiting period.

  • This may include ailments like Cataract, knee replacement, etc. (which are not pre-existing).

Do I get a discount on renewal of the policy with the same company?

Yes. Some of the insurance companies have this concept of loyalty benefit under which they offer discount on renewal of policy from the same company.

Is the policy applicable if hospitalization is for less than 24 hours?

Yes, your health insurance policy is very much applicable even if the hospitalization is less than 24 hours. This is known as Day Care Treatment. Here, 24 hours hospitalization is not required and you do have the scope of coverage too.

Day Care refers to any treatment or surgical procedure that is performed under general or local anaesthesia in medical clinic/hospital or a day care centre requiring hospitalization for a period of less than 24 hours because of technological advancement.

However, remember that OPD (out-patient department) are not a part of the Day Care treatments. The claim procedure too is nothing different than a normal regular hospitalization.

The below treatments are covered under Day Care Treatment:

  • Appendectomy

  • Angiography

  • Chemotherapy

  • Colonoscopy

  • Eye Surgery

  • Radiotherapy

  • Lithotripsy

  • Hydrocele

  • Piles / Fistula

  • Prostate

  • Sinusitis

  • Liver aspiration

  • Dialysis

  • Sclerotherapy

What will happen if my policy lapses when I am hospitalized?

Case 1: When you are hospitalized just before the policy expiry date and have intimated the insurance company about the same before policy lapses (where the policy lapses while you are still in hospital), the company will pay the benefit as per the plan, and its terms and conditions.

Case 2: If the policy lapses and you are hospitalized during the grace period, the insurance company will pay the coverage as per the plan, and its terms and conditions, on being intimated about hospitalization during the grace period and it being subsequently renewed within the grace period.

How to calculate mediclaim policy premium?

Insurance companies determine the premium amount of your mediclaim policy that you will be eligible for on the basis of several parameters. Some of these are age, sum insured, geographical location, any pre-existing medical condition, number of members to be insured, the extent of coverage, etc. The final decision regarding premium calculation is taken by insurance companies after evaluating your unique needs and financial objectives, as per the guidelines set by IRDAI. The more comprehensive your requirements, the higher will be your premium payment.

What is mediclaim policy for employees?

Group mediclaim policies are specifically designed for employers, who can opt for it for their employees on the payment of pre-determined premiums. This policy enables employers to cover their employees on specific hospitalization and other related expenses, as defined in the policy document of the insurance company. Employees can also avail tax benefits under such policies.

What are the types of cashless mediclaim?

The following are the two types of cashless claims in mediclaim:

Cashless claims: Fill up the Preauthorization Request Form with accurate information and submit it to your insurance company to initiate the claim settlement process.

Cashless planned hospitalization: In the case of pre-planned hospitalization, you need to submit the completed Preauthorization Request Form at least 72 hours before your hospitalization. This enables the insurer to ensure a streamlined and seamless claim settlement.

Cashless emergency hospitalization: For emergency hospitalization as a result of accident or critical illness, you are expected to present your mediclaim ID at the network hospital during admission. Further, the completed Preauthorization Request Form can be submitted within 4 hours of hospitalization to initiate the claim settlement process. Hence, it is essential for you to carry your mediclaim ID with you at all times.

What is individual mediclaim policy?

Individual Mediclaim, as the name suggests, is designed only for the policyholder. It insures him/her against hospitalization and other related expenses.

Which mediclaim policy is best for family?

Family Floater is especially designed for offering mediclaim benefits to your entire family, covering them against hospitalization and other related expenditures.

What happens if the primary insured person covered under a family floater policy dies?

In case the primary insured dies post hospitalization, then the claimable health expenses would be reimbursed. If the primary insured is also eldest member in the family, then for the succeeding years after the death of primary insured the premium would be calculated on the basis of the age of next eldest member. For this to happen, the family should fill up change of request form provided by the insurer.

Please note that in case there were only two members covered under the policy, the family floater plan would be converted to an individual plan.

How is TPA different from an insurance company?

TPA is a Third Party Administrator licensed by IRDAI to act as a service provider to all insurance companies. They facilitate the smooth functioning of health insurance policies by offering their value added services including claims management, dispatch of policy documents and health cards, post sales services, etc.

I have just bought a mediclaim policy for my family. My daughter is unwell and needs hospitalization. Can I request for a cashless treatment?

Most mediclaim policies have a compulsory waiting period of 30 days (except accidental injuries). If you have already exceeded this waiting period, you can very well request for a cashless treatment if you choose to admit your daughter in a network hospital of your insurance company.

Can I claim my expenses before and after the surgery I have just undergone?

Yes, you can. Most mediclaim policies cover expenses of 30 days before and 60-120 days after hospitalization. Kindly check the policy wordings of your insurance policy to check this clause.

Are there any limits on number of claims I raise on my mediclaim policy?

Well, no. You can claim as many times as the need arises during the policy period up to a maximum of your sum insured amount.

If I buy a mediclaim policy in Mumbai, can I claim on it in Bangalore?

Yes. Mediclaim policies are valid all over India and you can raise a claim for the treatment sought in any registered hospital in India.

Will I have to undergo any pre-policy medical checkup?

Honestly, this decision lies entirely with the insurance company. If they feel the need to do so, you will have to undergo the pre-issuance medical checkup at an authorized diagnostic centre suggested by them as per your convenience. Typically, a medical checkup is triggered for those above 45 years of age or anyone suffering from any pre-existing medical condition to evaluate the depth of risk involved.

Can I avail domiciliary treatment under the Mediclaim policy?

Yes, you can avail a domiciliary treatment. However, only domiciliary hospitalization is covered under the mediclaim policy. This treatment should be for any sickness/illness that requires home hospitalization due to the below reasons:

  • The patient is not in a condition to be moved to the hospital or the hospital itself lacks accommodation.

  • Pre and post-hospitalization expenses and treatments for diseases like Epilepsy, Asthma, Chronic disorders, Bronchitis, Cough, Cold, Hypertension, Influenza, Dysentery or Diarrhea etc. are not paid under the domiciliary hospitalization benefits.

Can I avail treatment at any hospital?

You can take treatment only under the network hospitals, empaneled with the insurance company. The hospital should fulfill the below conditions:

  • Hospital should have qualified doctors and trained nurses 24*7.
  • Hospital should have at least 15 in-patient beds.
  • Hospital should be fully equipped with a good operation theatre.

You can also avail the treatment at any Ayurvedic hospitals fulfilling all the conditions except the operation theatre criteria.

Can I avail tax benefits under the Mediclaim insurance policy?

Yes, mediclaim insurance policy offers you tax benefits. Though this shouldn’t be the sole motive of opting for the mediclaim insurance, it does give you a tax benefit on your health insurance under Section 80D of the Income Tax Act.

  • You can avail tax benefit of Rs.15000 if you are below 60 years of age. However, if you are a senior citizen, you can avail a tax benefit of Rs.20, 000.
  • If you pay the mediclaim insurance premium for your dependent parents, then you are eligible for an additional deduction up of to a maximum of Rs.15, 000. However, if your parents are senior citizens, you can avail a total deduction of Rs.20, 000.

This means, if you are paying premiums for yourself as well as your parents, you can claim a maximum amount of Rs.35, 000 under the Income Tax Act.

What types of mediclaim insurance policies are available in India?

There are two types of mediclaim insurance policies.

  • Individual Mediclaim Policy – Only an individual or a single person is covered here. The premium here is calculated as per the age of the individual. The insured can claim the entire sum assured under this type of mediclaim insurance. If the sum assured is Rs.10 lakh, then you can claim up to Rs.10 lakh only. No amount exceeding Rs.10 lakh can be claimed.
  • Family Floater Mediclaim Policy – The entire family can be covered under this type of mediclaim policy. Here, the premium is calculated according to the age of the eldest member of the policy. If the sum assured is Rs.10 lakh then either any one person individually or all the entire family can claim the sum assured not exceeding Rs.10 lakh.

How are claims settled under the mediclaim insurance if I want to register one?

The claims under the mediclaim insurance are settled in 2 ways:

  • Cashless settlement – Here, the hospitalization expenses are collected from the insurance companies directly or from their Third Party Administrator’s (TPA’s). You simply need to get hospitalized under any hospitals empaneled with the insurance company and produce your health card issued by your insurance company.

  • Reimbursement settlement – Here, you will have to pay the hospitalization expenses directly to the hospital and then claim a reimbursement from the insurance company to settle the bills.

Is there any waiting period when my expenses will not be settled, in case of emergency?

In case the insured is hospitalized due to the accidental emergency, the insurance company pays the coverage as per the health plan. That is, accidental emergencies are covered from the date of insurance issuance.

Apart from that, to cover any medical treatment cost there is a 30 to 90 days of waiting period depending on the insurer. Moreover, there is specific waiting period for specific ailments.

It is advisable to check all the clauses related to the waiting period before the purchase of health plan and lodging a claim.

What type of medical expenses are tax deductible?

Expenses incurred towards conducting health check-ups for own and family members are eligible for tax deduction up to Rs. 5,000 within the overall limit.

Can I transfer my mediclaim policy to another company?

Yes, you can transfer your Mediclaim Policy to another company.

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