Mediclaim Policy

A Mediclaim policy provides coverage against medical expenses that one might incur. Individuals who have a Mediclaim policy can either raise a cashless or reimbursement claim. These policies also provide tax benefits to policyholders.
A Mediclaim policy provides the policyholder with financial assistance through cashless facilities or reimbursement during medical treatments and hospitalisation. It covers the insured against any medical expense that might occur during the policy period and also offers tax benefits under section 80D of the Income Tax Act of India, 1961.

What is Mediclaim?

A Mediclaim is a form of insurance wherein the insurance providers reimburse the policyholder for any medical expenses that he/she might have incurred in the policy period. The insured can either submit the relevant bills to get reimbursed or avail completely cashless facilities at the insurer's network hospitals. Skyrocketing medical inflation rates have made Mediclaim policies or health plans a necessity to make healthcare affordable for the larger masses. Mediclaim policy is a type of health insurance that offers a health cover for illnesses and hospitalisation up to a specific sum insured. Such policies are valid for a particular period after which the policyholder has to renew it to enjoy the benefits.

Mentioned below are some important aspects of a Mediclaim policy:
Premiums : The premiums paid for Mediclaim policies differ from one insurer to another however, the factors that influence the amount are constant. Age, sum insured, policy period, etc., are a few of the factors that affect the premium.
Age : Mediclaim policies can be bought only if the consumer falls in the specified age group. Usually, insurers have an entry age of 18 years and an exit age of 65 years. However, sometimes the age group can start at 5 years and go up to 80 years.
Family cover : In a family cover, the policyholder can pay a master premium to cover his/her entire family instead of buying individual policies.
Overseas Mediclaim policies: Many insurers provide overseas Mediclaim policies under which the insurer can seek treatment in both India and abroad. However, such policies have certain conditions attached to them.
Claims : Claims are usually made through third-party administrators (TPA), but some insurers deal with claims in-house.
Types: Mediclaim policies cater to different needs and different individuals. One can choose from individual policies, group policies, critical illness policies, senior citizen policies, and maternity policies.
Tax benefits : Under section 80D of the Income Tax Act of India, 1961, policyholders can claim a tax deduction of Rs.25,000 against the premium paid for Mediclaim policies. The exemption limit is Rs.30,000 for senior citizens. Policyholders can claim an additional exemption of Rs.25,000 if they are paying the policy premiums for their parents.

The terms health insurance and Mediclaim policy are often used synonymously, however, both of them are different in nature. A Mediclaim policy works on an indemnity basis which means that any medical expense incurred by the policyholder will be reimbursed by the insurers. On the other hand, health insurance plans function on the benefit principle where a certain lump sum is paid out if the policyholder meets with a certain eventuality like critical illness, accident, etc.
Listed below are some of the major distinctions between a Mediclaim policy and health insurance:

Features Mediclaim Policy Health Insurance
Coverage Mediclaim policies cover medical expenses and hospitalisation charges. Health insurance covers hospitalisation charges along with additional expenses like ambulance charges, daily cash allowance, etc.
Claim Policyholders can make unlimited claims until the sum insured is exhausted. Policyholders are given a lump-sum amount if they meet with an accident or are diagnosed with a critical illness. The cover ceases to exist after the pay-out.
Sum insured Mediclaim policies usually have a lower sum insured. Comprehensive health insurance plans offer a higher sum insured that can go up to a crore at times.

We Provides the following types of Mediclaim Policies

  • Individual Mediclaim : An individual Mediclaim policy covers the policyholder alone against any medical expenses.

  • Family floater : In a family floater Mediclaim plan, a master premium is paid that financially supports the family members against any medical liabilities.

  • Group Mediclaim : In group Mediclaim policies, an employer or a person-in-charge of a group buys the policy for the employees/members. It is usually an addition to the compensation provided by the employer.

  • Senior citizen Mediclaim : Such policies are specifically designed for senior citizens and often have special provisions or require testing.

  • Critical illness Mediclaim: Mediclaim policies cover the medical expenses pertaining to the treatment of critical illnesses like cancer, kidney failure, multiple sclerosis, etc.

  • Overseas Mediclaim : An overseas Mediclaim policy allows the insured to make claims for medical expenses that were incurred outside India.

  • Low-cost Mediclaim: Low-cost Mediclaim policies are targeted at the underprivileged section of the society. Such policies are usually bought by employers in small and medium scale industries to insure their employees at low premiums.

  • Day-care treatment : It consists of the expenses pertaining to advanced medical treatments that do not require the patient to stay in the hospital for 24 hours.

  • Pre and post-hospitalization charges : Mediclaim policies usually cover the expenses incurred during the period before and after hospitalization. The covered period varies between insurers and can range from 30 days to 90 days. Such expenses usually include doctor's consultation fees, lab tests, and follow-up check-ups.

  • Hospital stay : Hospital room rent can get very expensive at times. However, Mediclaim policies cover the room rent as well. Rent for wards, private rooms, or ICU is fully reimbursed by the insurers or availed through cashless facility.

  • Medical professional's fee: Certain Mediclaim policies also cover the costs of consultation fees and medical professional's fees such as doctor's fees, nurse's fees, etc.

Exclusions refer to the diseases and medical conditions that are not covered under the policy. When buying a policy, the first 30 days are treated as the waiting period where claims can't be made. If the policyholder gets diagnosed with any disease in that duration, it won't be covered by the insurer.
The exclusions differ from one insurer to another. However, here are some medical conditions that are usually excluded from the policy:

  • Pre-existing diseases.

  • Sexually transmitted diseases (Including HIV/AIDs)

  • Pregnancy and childbirth.

  • Dental treatments

  • Vaccination

  • Cosmetic surgery and obesity-related treatments

  • Plastic surgery

  • Hearing aid, contact lenses, etc.

Mentioned below are some notable benefits of a Mediclaim policy:

  • Cost-effective: It is an affordable way to combat rising healthcare costs.

  • Medical emergencies: Investing in a Mediclaim policy can prevent any financial stress during medical emergencies like accidents.

  • Cashless claims: It offers cashless facilities where the policyholder doesn't have to shell out any money from his/her pocket during hospitalization. The insurer pays the hospital directly.

  • Tax benefits : Investing in a Mediclaim policy allows the policyholder to claim tax benefits under section 80D of the Income Tax Act of India, 1961.