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All You Ever Wanted To Know About Mediclaim

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.

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?

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 of Mediclaim Policy

  • Can be renewed annually. Some insurers offer renewals every 2 or 3 years
  • Can be opted for Individual or Family Floater
  • For anyone between the age of 91 days to 65 years
  • Covered pre-existing medical conditions after a waiting period of 3-5 years
  • Can be bought online without any paperwork
  • Sum insured opted can be as much as Rs. 50 lakhs
  • Can be ported to different insurer at the time of renewal

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'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?

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.

How to Claim on the Mediclaim Policy?

With an advancement in the insurance sector, claiming on your mediclaim policy has become quite convenient, hassle free and time saving. As you are aware, you can claim via two ways – Cashless & Reimbursement.

If you wish to opt for Cashless Treatment in a network hospital, you must contact the TPA (Third Party Administrator) help desk at the time of hospital admission. A claim form along with doctor’s reports have to be submitted to seek approval for the cashless treatment. If the request is approved, the insurance company/TPA settles the bills for the expenses directly with the hospital without involving the policy holder. This is the most convenient method of claiming on your mediclaim policy.

If, due to any reasons, you are unable to seek cashless treatment, you can opt for Reimbursement. Once the treatment is sought in the hospital and the amount settled, the claim form along with the discharge summary and all other related prescriptions and doctor’s reports need to be sent to the insurance company/TPA. The insurance company/TPA will then scrutinize the documents for correctness and check against the policy terms before taking the final decision on claim settlement. Typically, this process takes around 15-25 business days.

How Can Coverfox Help You Choose the Right Mediclaim Policy?

  • 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.

Frequently Asked Questions

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.

Planning to Buy a Mediclaim Policy?

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