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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.
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.
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.
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
Read About Difference Between Mediclaim Policy and Health Insurance Policy
| Criteria | Mediclaim Policy | Health Insurance |
|---|---|---|
| Features | This varies from one insurance provider to another | The features of a health insurance plan of a specific sum insured are more or less the same across insurers |
| Coverage | Hospitalization, accident related expenses, pre-decided diseases | Complete comprehensive cover which includes pre/post hospitalization, medical treatment expenses, accidents, loss of income |
| Eligibility | Every Individual | Every Individual |
| Types of Policies | Individual Mediclaim Family-Floater | Individual Health Family-Floater, Critical Illness, Cancer Insurance, Accidental Death Cover |
| Sub-Limits | Subject to the sum insured and room rent | Subject to the sum insured and room rent |
| Sum Assured | Does not exceed ₹5 lakhs | Does not exceed ₹6 crore per year |
| Co-payment | 10-30%, Depends on the policy issued | 10-30%, Depends on the policy issued |
| Waiting Period | 30 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 Hospitals | PAN India | PAN India |
| Add-ons | None | Rider Options such as Accidental Death Cover, Critical Illness Cover, Maternity cover, Disability Cover, etc |
| Free-look period | None | 15-30 days from the date of policy purchase |
| Cashless Procedure | Yes, across listed network hospitals | Yes, across listed network hospitals |
| Claims | Online 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 Age | 65-75 years | 65-75 years or lifetime |
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.
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.
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.
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.
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
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.
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.
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.
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.
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 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.
Copy of the First Information Report (FIR) or Panchanama/Police complaint
Copy of Post Mortem report (PMR)/Autopsy and Viscera report
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.
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.
Here are three things that you have to consider while buying an effective mediclaim plan that meets your unique needs.
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 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.
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.
