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Mediclaim Policy


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Mediclaim Policy

There has been an increase in the cost of healthcare services as a result of medical inflation. As a result of a medical emergency, your lifetime savings will be gone in no time if you end up being taken to the hospital as a result of a medical emergency.

When it comes to paying for expensive medical care without depleting your resources, having a health insurance policy is one of the easiest and most convenient ways to do so.

Mediclaim Policy: What is it?

A Mediclaim policy is a type of health insurance that pays exclusively for hospital-related medical expenses. As long as the total insured limit has been reached, medical coverage for hospitalization costs can be provided.

The Mediclaim is available on an individual basis and on the basis of a floater amount insured, and it also provides the policyholder with cashless treatment options at hospitals that are part of the insurer’s network.

Benefits of Buying a Mediclaim Policy

Hospitalization and healthcare costs are going through the roof as a result of the rise in lifestyle disorders nowadays.

You can receive financial assistance during hospitalization in the event of a medical emergency by buying a medical insurance policy. Here are just a few of the many advantages of buying a medical policy:

  1. Cost-effective: Using medical policy coverage will help you get healthcare without depleting all of your funds.
  2. Cashless Treatment: Your insurance provider’s network hospitals all offer cashless hospitalization services, so there are never any out-of-pocket costs in the event of a medical emergency.
  3. Financial Stress Reduction: By providing financial support in the event of a medical emergency, it lessens the financial strain on the policyholder and his or her family.
  4. Family and Individual Floater Cover: Individual and family floater plans are both offered on the market.
  5. Hospitalization costs: The Mediclaim policy pays for inpatient hospital costs associated with a sickness or unintentional damage, including OT costs, doctor’s fees, nursing costs, medication costs, etc.
  6. Additional perks: It includes a number of extra perks, including ICU fees and lodging rent.
  7. Tax Exemption Advantages: The annual policy premium can be used to get tax advantages under Section 80D.

Types of Mediclaim Policies in India

In India, there are several kinds of medical insurance policies. You may select a policy based on your healthcare requirements and receive medical care in confidence.
Let’s examine the various Mediclaim policy categories:

individual mediclaim policy
Individual Mediclaim Policy

Only the policyholder is covered under a personal medical insurance policy. Under this sort of coverage, only one person may use the Mediclaim policy benefits in exchange for the premium.
In India, a number of health insurance providers provide individual medical coverage.

family Floater mediclaim policy
Family Floater Mediclaim Policy

A family floater mediclaim policy covers the policyholder’s immediate family, such as parents, spouses, and kids. Each family member has access to the same total insured amount under this type of coverage on a floater basis.

Seniorcitizen mediclaim policy
Senior Citizen Mediclaim Policy

The purpose of a senior citizen’s mediclaim policy is to pay for hospitalization costs incurred by seniors over the age of 60.
The senior citizen health insurance policy coverage is tailored to meet their specific medical requirements.

Critical illness mediclaim policy
Critical Illness Mediclaim Policy

Because critical illnesses have substantial medical costs, this policy covers coverage for conditions like cancer, renal failure, cardiovascular diseases, etc.

Oversea mediclaim policy
Overseas Mediclaim Policy

With this kind of, you are able to submit claims for hospitalisation costs that you incurred while travelling abroad.

Low Cost mediclaim policy
Low-Cost Mediclaim policy

This kind of policy is an option for people who want less protection. Additionally, these measures support the socially disadvantaged. Employers in small and medium-sized businesses typically get this insurance to provide affordable coverage for their workers.

Comparison Between Mediclaim Policy and Health Insurance:

Mediclaim is often used as a synonym for health insurance plans. Both these types of health plans are indemnity comprehensive health insurance plans but there are quite a few differences between the two, such as:

ParametersHealth InsuranceMediclaim Policy
MeaningIn addition to hospitalisation costs, a health insurance plan covers medical charges. Additionally, it provides a one-time payment for the diagnosis of any serious sickness.The medical expenses incurred exclusively while in the hospital are covered by the Mediclaim policy. 
Coverage scopeIt pays for things like ambulance fees, hospital bills, critical illnesses, daycare treatments, etc.It offers coverage for hospitalisation due to a sickness or accident. 
Add-on coversIt offers a variety of add-on coverages, including critical sickness insurance, maternity benefits, international coverage, etc. It does not include any additional covers.
PremiumCompared to a mediclaim policy, the cost of health insurance is higher since it offers whole coverage.Due to the policy’s restricted coverage, the premium cost is low.

How Does Medical Insurance Work?

Mediclaim begins with the selection of the appropriate policy. Considering the variety of health insurance policies available, each with different coverage limits, premiums, and deductibles, be sure to review the policy terms and conditions to ensure they meet your needs.

To activate your policy, you must pay the premiums once you have chosen a policy that meets your needs.

If you require medical treatment following coverage, visit a network hospital and provide your policy details to the third-party administrator (TPA).

The remaining steps will be handled by the TPA. When filing a reimbursement claim, you will need to submit all receipts and bills related to your medical treatment.

Your medical expenses will be reimbursed by your health insurance company if your claim is approved. It is important to keep in mind that your insurance company will only reimburse you for costs covered by your policy.

To ensure that you understand the coverage limits and deductibles, you should carefully review the policy terms and conditions.

What is covered in a Mediclaim Policy?

Good mediclaim policy coverage will protect you from a variety of medical costs; however, the specifics will differ across policies.

The following are some of the most typical components of a Mediclaim policy:

  1. In-patient Hospitalisation Costs:
    This category comprises all medical costs incurred while the policyholder or insurance beneficiaries were in the hospital. It covers costs for things like diagnostic tests, OT fees, medications, blood, x-rays, oxygen, etc.

  2. Pre- and Post-Hospitalisation Expenses:
    Medical expenses incurred prior to being admitted to the hospital and after discharge from the hospital are covered. To find out if this kind of hospitalization is covered by your insurance, you must speak with the insurer.

  3. Day-care Costs:
    Medical costs associated with cutting-edge procedures that don’t keep the patient in the hospital for more than 24 hours are reimbursed.

  4. Room rent:
    Through the cashless facility, costs for standard wards or intensive care units (ICU) are completely covered, subject to the applicable limits, if any.

  5. Doctor’s or Medical Professional’s Fee:
    The cost of a doctor’s consultation or that of a medical professional, such as a nurse, is covered.

This list is not exhaustive but only indicative.

What is Not Covered in the Mediclaim Policy?

Every medical insurance policy has specific exclusions, and they differ between insurance providers. The following are some typical mediclaim policy exclusions, unless specifically :

  1. Pre-existing Medical illnesses:
    Until the conclusion of the waiting period, the majority of Mediclaim policies do not cover pre-existing medical illnesses like diabetes, high blood pressure, etc.
    While the waiting time is usually 30 days for insurance in order to file a claim, except in personal accident cases, it may be up to a year or longer if there are pre-existing medical issues.

  2. Alternative Therapies:
    Alternative therapies like homoeopathy, acupuncture, yoga, etc. are not covered by Mediclaim health insurance coverage.

  3. Cosmetic surgeries:
    Any type of medical care, such as plastic surgery, that aims to improve a person’s appearance is not covered by medical insurance. However, hospitalization for aesthetic procedures after an accident or injury can be covered.

  4. Transmission-related Diseases:
    Usually, Mediclaim health insurance policies permanently exclude coverage for any transmission-related diseases, such as HIV and AIDS.

  5. Congenital abnormalities:
    In India, the majority of medical insurance policies do not cover genetic abnormalities or pre-existing ailments.

How is the Mediclaim Premium Calculated?

Age, location, the amount insured, any existing medical conditions (if any), the scope of coverage, the number of covered members, etc. are all taken into account when insurance firms determine the mediclaim policy price.

However, in accordance with IRDAI norms, the insurer will determine the ultimate rate depending on your individual needs and financial requirements.

Things to Remember When Buying the Best Mediclaim Policy

  1. Sum Insured:
    While choosing the best mediclaim policy, you must ensure that you select a sum insured that is adequate or a coverage amount that is adequate.
    It is crucial that you choose a policy that is suited to your requirements regardless of the fact that you might have to pay a greater premium for a larger sum of money promised.

  2. Individual- Family Floater:
    Before you finalize your mediclaim policy, you should check to see if this coverage is for your entire family or just you.
    As opposed to this, the beneficiaries of a family floater-type medical insurance policy, on the other hand, would own the entire sum of the policy jointly with you.

  3. Co-payment:
    This provision stipulates that the policyholder is responsible for paying a certain percentage of medical claims, while the insurer covers the rest of the costs related to medical care.

  4. Network of Hospitals:
    It is important to choose an insurance company that has a large network of hospitals because only these hospitals provide a cashless facility.
    As a result, you will be able to choose from a variety of options available to you. Insurance companies have a waiting time before which you cannot make a claim for any medical costs. Additionally, there is a waiting time for pre-existing conditions with insurance carriers.

  5. Add-ons:
    Most insurance companies do not provide add-ons for their mediclaim policies, but if they do, you can purchase them to expand your insurance coverage. Please be aware that adding on will raise the cost of your insurance.

Eligibility Criteria of a Mediclaim Policy

Minimum ageChildren: 90 days Adult: 18 years 
Maximum ageChildren: 25 years Adult: 65 years 
Family Members Covered Self, spouse, parents with children who are dependent, and in-laws
Renewability Lifetime

Documents Required

The list of papers that must be supplied in order to obtain a Mediclaim policy is provided below:

  • Completed application form Age Verification: Passport, Aadhar Card, PAN Card, Voter ID Card, etc.
  • Identification documents include a driver’s license, passport, PAN card, and Aadhar card.
  • Driving licenses, ration cards, utility bills, Aadhar cards, passports, and voter ID cards are examples of address proof.
  • Two photos in passport size
  • Health test results

Mediclaim Policy Claim Process

A reimbursement claim and a cashless claim are the two sorts of claims that you may make under a mediclaim policy. The claim process is described below.

Cashless claim Process

As the insurer pays the hospital’s bill directly, cashless claims guarantee that a patient will receive cashless care in a network hospital. This means that the insured person owes the hospital nothing for the care they get.

To submit a cashless claim, follow the instructions below:

  • Visit a hospital that is affiliated with your insurance provider to obtain treatment.
  • Pick up pre-authorization paperwork from the hospital’s insurance counter.
  • Complete the form as required, giving accurate information, and have the hospital stamp it.
  • The Third Party Administrator (TPA) or the insurer will receive the document from the hospital for approval.
  • The company will thoroughly review the paperwork before approving the therapy and fax confirmation of payment to the hospital.
  • Obtain treatment, and after release, sign all paperwork.
  • The hospital bill sum will be covered by your insurance.

Reimbursement claim Process

As a result, if you need to file a reimbursement claim, it is essential that you notify your insurance provider as soon as a hospitalisation has taken place or is about to take place.

This can be done by contacting the customer service department of your insurance company, or by sending an email to them.

The hospital should be able to provide you with all your medical records once the treatment has been completed.

It is important that you provide your insurance company with a copy of the original discharge card, the claim form, as well as any hospital bills, payment receipts, and pharmaceutical invoices in order for you to be reimbursed.

As soon as your claim has been examined and the reimbursement sum has been paid, the insurance provider will notify you.


A medical emergency can occur at any time, and if you are not covered by a health insurance policy, then you may find yourself with a massive medical bill in the event that you are hospitalized.

We ignore and do not cover our family and ourselves with a mediclaim policy despite the rising costs of healthcare, despite the fact that they are expensive.

As a result, we find ourselves in a precarious position when it comes to medical emergencies. To protect yourself from financial risks, it is important to be proactive and take the necessary steps to protect yourself and your family from them.

The decision to invest in a health insurance policy is one that you should make wisely.

Frequently Asked Questions

There are requirements that must be met for a domiciliary hospitalisation.
This includes medical care if it lasts more than three days, the patient's condition prevents moving to a hospital for treatment, or if there isn't room for them in a hospital.
There are also several exceptions from the domiciliary hospitalisation policy. To learn about the conditions that are not covered, see the policy wording.

In accordance with IRDAI rules, all Mediclaim plans must provide coverage for hospitalisation costs associated with the coronavirus. A few insurance companies also supply clients with particular coronavirus health insurance plans. It is preferable to confirm with your insurer, nevertheless, if COVID-19 treatment costs are covered.

It pays for all hospital costs, including OT fees, medication costs, oxygen costs, blood costs, and other costs incurred during treatment. Additionally, it covers the expense of cutting-edge medical procedures and diagnostic testing.

The age requirement to purchase coverage often varies from insurer to insurer. It typically covers anyone between the ages of 18 and 65 and even includes newborns beginning at 91 days old.
Some schemes provide perpetually renewable resources. Before selecting a plan, you must review the qualifying requirements of medical insurance coverage.

I would like to tell you that one of the first things you need to do is to inform the TPA of your hospitalization as soon as possible, providing them with information about your policy, the hospital, and the necessary treatment.
The claim form must be filled out and delivered to the TPA or the insurer along with any necessary paperwork, along with the claim form.
Whenever you make a reimbursement claim, the claim amount will be paid to you as soon as the insurance company receives all of the required paperwork from you.
There are a couple of things to keep in mind when making a cashless claim: if you receive a pre-authorization before your treatment begins, the insurer pays the hospital directly.

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