In this day and age, health insurance has become one of the utmost requirements for securing one’s financial well being. Though awareness about medical insurance has increased in the recent years, the overall insurance penetration in India is still on the lower side. It is expected that medical inflation in India is all set to increase at the rate of 15 to 20% every year. Considering the surging expenses, it is wise to have a mediclaim policy that offers comprehensive coverage against various illnesses.
Mediclaim is a type of health insurance product that offers protection against various hospitalisation expenses incurred by the insured. In India, mediclaim policy benefits are offered either as reimbursement benefits or cashless treatment benefits. One of the things that must be noted in mediclaim is that it pays only for the actual hospitalisation or domiciliary hospitalisation expenses incurred by the insured person.
To gain a full understanding of how mediclaim policies work in India, it is necessary to understand the terms commonly used in the health insurance industry.
In India, there are about 29 non-life insurance companies in the market. Most of them in the list are general insurance companies that offer a wide range of insurance services in various domains such as health, travel, motor, home, personal accident, etc. Mediclaim policies are offered by almost all general insurance companies in the country. In addition to the general insurers, there are standalone health insurance companies that are exclusively licensed to provide insurance service in health, travel, and personal accident domains.
All these companies have different varieties of health insurance plans.
The 5 standalone health insurance companies operating in India can be listed as follows:
In addition to the public sector companies and standalone service providers, we have an array of private sector general insurance companies providing service in the Indian market. Some of the top players in the market include HDFC ERGO, ICICI Lombard, Bharti Axa, IFFCO Tokio, Future Generali,Royal Sundaram, Reliance General, etc.
Though the terms mediclaim and health insurance are used interchangeably by the general public, industry experts say that there is a subtle difference between the two. Health insurance is a much broader term that covers a range of insurance products intended to provide coverage against health issues and ailments. Mediclaim, on the other hand, is limited to the coverage intended for actual medical expenses incurred by the policyholders.
|This is a broader term that comprises all kinds of products included in the ambit. This also includes benefit products that provide the full sum insured money upon the occurrence of an event that may give rise to a claim.||Mediclaim focuses mainly on indemnity policies that offer coverage against various hospitalisation expenses. The actual hospitalisation expenses incurred by policyholders are covered in mediclaim policies.|
|Health insurance is also available for eventualities that do not require hospitalisation.||Mediclaim requires hospitalisation of the policyholder in order to provide coverage.|
|A critical illness policy that pays the full sum insured amount to the policyholder upon the first diagnosis is also a type of health insurance.||Mediclaim policies do not have any provision in which the full sum insured amount is paid to the policyholder.|
In a mediclaim policy, the policyholder can make any number of claims till the full sum insured amount is exhausted within a particular policy term.
Mediclaim policies are available to customers in different forms. The flexible nature of these policies allow customers to choose one based on his/her specific requirements. Some of the common types of mediclaim policies can be listed as follows:
A medical insurance policy provides coverage against a range of expenses incurred by the insured. Some of the major medical expenses covered by a mediclaim policy can be given as follows:
|Expenses covered||Extent of coverage|
|In-patient hospitalisation expenses||All mediclaim policies provide full coverage up to the maximum sum insured limit. Medical expenses including room boarding charges, medical practitioner’s fees, cost of medicines, etc. are covered under this policy.|
|Day care treatment||Most insurers provide coverage for day care procedures like chemotherapy, dialysis, etc. that do not require 24-hour hospitalisation. The list of procedures covered under the day care treatment are usually provided in the policy document.|
|Domiciliary hospitalisation||For policyholders who cannot visit a hospital for treatment, domiciliary hospitalisation expenses are covered for a specific period of time. Sum insurers have sublimits for domiciliary hospitalisation.|
|Pre and post hospitalisation expenses||Almost all major insurance companies provide coverage for the pre and post hospitalisation expenses incurred by a policyholder. The coverage will be extended only for a specific number of days (e.g. 30 days or 60 days). Expenses incurred only for the primary reason of hospitalisation are covered in this benefit.|
|Ambulance charges||Most insurance companies operating in the market have provisions for covering the ambulance charges up to the specified sub limit.|
|Daily cash allowance||Some insurers provide this as an add-on cover, and some provide this under a regular policy. It offers a specified cash allowance for the non-medical expenses incurred during a hospital stay.|
|Health checkup||If policyholders do not make any claim for a specified period of time, the insurance companies offer free health checkup for a certain amount.|
There are certain expenses for which a mediclaim policy cannot be held liable to provide coverage. The most common exclusions listed out by mediclaim companies are as follows:
There are many cases where people do not appreciate the importance of having a mediclaim policy. A mediclaim policy comes with a lot of benefits that cannot be ignored at any cost. When you have the right mediclaim policy, you can experience the following benefits:
In addition to the major benefits listed above, a mediclaim policy offers tax relief as per Section 80D of the Income Tax Act. The premium amount paid towards a health insurance plan for you and your family is eligible for tax relief. If you have dependent parents, you can also claim the tax relief applicable for senior citizens. The deduction limit allowed under Section 80D and Section 80DD can be listed as follows:
Most of the urban working population do not have the time to visit a company’s branch office and apply for an insurance cover. With the advent of technology, more and more people are now choosing to buying their mediclaim policy online. In order to cater to their needs, health insurers have made the entire process extremely simple in the recent days.
Anything related to a mediclaim policy can be obtained online. If you are looking for a product’s brochure and policy document, they can be downloaded from the company’s official website. Any query regarding a particular mediclaim policy can cleared by accessing the company’s customer service. Some of the top companies in the market even have automated chatbots to help customers access the right information from the company’s official website.
Information availability has made it possible for customers to compare the features of multiple insurers. You can also use the service of a third-party aggregator like Bankbazaar to provide unbiased information about various insurance policies in the market. When you are comparing mediclaim policies, you must choose the best one suitable for your individual requirements.
The health insurance market is currently flooded with a huge number of mediclaim policies. Choosing the best one can be a bit of a challenge. First, you must narrow down the mediclaim policies based on the sum insured you need. Cost is a major factor, but it must not be the sole focus when buying insurance. Make sure that the medical insurance policy has the right mix of coverage, cost efficiency, and ease in claim settlement.
Health insurance is all about providing financial help when a policyholder faces an adverse medical emergency. A mediclaim policy works similar to that of a community fund. Everybody contributes with yearly policy premiums and financial assistance is offered to those who are in need. A mediclaim policy provides coverage for hospitalisation caused by various illnesses and accidents. In India, all rules related to health insurance are formulated and monitored by the Insurance Regulatory and Development Authority of India (IRDAI).
Some of the major health insurance companies operating in India are already listed here. A customer seeking coverage from an insurer will file an application for a specific policy. Nowadays, most health insurance applications are filed online. Also, most health insurers have started offering paperless policies that require little to no paperwork. After the application, the insurer will match the customer’s request with the eligibility criteria and approve the request after confirmation. The policy will be active as soon as it is issued to the customer.
All customers have to comply with the term and conditions set forth by the insurer. These terms are monitored by the IRDAI. Considering the heavy competition in the health insurance market, companies offer flexible terms for the customers. All terms and conditions related to a policy will be provided in the policy document issued to the customer. It also dictates the way in which claims can be made in a mediclaim policy.
Most of the top health insurance companies have simplified the claim process to the benefit of their customers. If customers contact the customer service of the company, the customer support team will guide them on how to proceed with the claim filing. The claim procedure is simple and straightforward with most insurers. For cashless treatment claims, the approval has to be obtained beforehand from the company. For reimbursement claims, the insured must submit all the bills and receipts along with the claim form. Some companies handle claim processing on their own, while others use the service of a third-party administrator (TPA) to handle all claims.
Before you sign up for a mediclaim policy, you must consider the following things in order to choose the right one:
With the advent of technology, most insurance companies have made the claim settlement process easy for the benefit of their customers. Most of the top insurers allow the entire process to happen online without the need for customers to visit a branch office. When it comes to claim settlement, it could either be cashless treatment or reimbursement claims. Let’s the process for both forms of claims in detail.
Cashless treatment is possible only in the network hospitals of your insurer. So, you must first make sure that you are getting admitted in a network hospital that has tie-up with your insurer. Even if the diagnosis is made in different hospital, you can transfer yourself to a network facility to initiate the treatment. For planned hospitalisation, the insurer must be informed at least 48 hours (may vary) before admission in a hospital. For emergency hospitalisation, the insurer must be notified within 24 hours of hospital admission.
Once you are in the hospital, you must ask for a pre-authorisation form from the hospital. All your policy details must be filled in the form and sent to the insurer or TPA through fax. The insurer or TPA will check the validity of the claim and send the approval to the hospital. Most of the top insurers take just a few hours to send the approval. The approval time may vary from one insurer to another. However, there are provisions in a mediclaim policy to treat emergency cases instantly even before receiving the approval.
For reimbursement claims, the claim request can be submitted once the treatment is over. Even in this case, the insurer must be notified before the initiation of the treatment. It is necessary to get treatment in a facility that is approved as a hospital. It is always safe to get treatment in a network hospital to make sure that the claim process goes smooth. Once the treatment is over, the claim request must be submitted within a maximum of 7 days (this time period may vary depending upon the insurer).
At the time of filing a claim, the insured must provide various bills and receipts for the proof of medical treatment. All details regarding your mediclaim policy must be filled in carefully without any errors. After the submission of all the required documents, the insurer or TPA will initiate the claim proceedings. The documents will be verified to ensure that there is no malpractice. Once the document verification is over, the company will intimate the insured person regarding the approval or rejection of the claim. Typically, it takes about 15 days to communicate this information to the insured. Most insurers take about 30 days to provide the settlement amount to the insured.
During the claim process, the insured must submit the following documents to initiate the claim proceedings:
1. Why is mediclaim important?
A mediclaim policy provides you with timely assistance and saves you from financial troubles. Unexpected expenses caused by medical emergencies will cause a dent in your family’s finances and lead to indebtedness. Moreover, healthcare is getting expensive every year in our country. To safeguard yourself from a potential financial mess, it is always better to have health insurance protection. If you are young working professional, the cost of mediclaim is not very high but the protection offered here is remarkable.
2. What is cashless treatment facility?
Cashless treatment allows you to get medical treatment without paying any money. This is a facility offered by most insurance companies through their tie-ups with major hospital networks in the country. All you have to do is produce your insurance details and send an authorisation request to the insurer. The hospital staff will guide you with the process once you produce your insurance details. Upon receiving the authorisation, the hospital will proceed with the treatment. Any medical bills related to the treatment will be sent directly to the insurer, and the insurer will provide compensation to the hospital.
3. How long should I wait before the policy coverage begins?
Once you have signed up for a mediclaim policy, there is an initial waiting period of 30 days. Any illnesses contracted during this period will not be covered. However, if there is an accidental hospitalisation, this initial waiting period will not apply.
4. What is a pre-existing illness? Is it covered by a mediclaim policy?
Any illnesses that you already have at the time of taking a policy are called pre-existing illnesses. It is a must to disclose this information to the insurer at the time of sign up. Most mediclaim policies provide coverage for pre-existing illnesses after a certain waiting period. In some cases, the waiting period for pre-existing illnesses may extend up to 4 years.
5. What is a group mediclaim policy?
Group mediclaim policies are intended for people belonging to a specific group. The most common form of group mediclaim is the insurance cover purchased by an employer to provide coverage for his employees.
6. Who should buy family floater mediclaim policies?
Family floater mediclaim policies are ideal for people who have dependent family members. If you have spouse, children, and parents, you may not be able to afford buying individual policies for everyone. In this case, you can cover all your family members within the same policy by paying a single premium. The sum insured amount can be used by any family member at the time of need.
7. How can I renew my mediclaim policy?
You can renew your mediclaim policy simply by visiting the official website of your insurer. If you are not sure about how to do it, you can get the help of the customer service. You may also renew your insurance cover by visiting the branch office of an insurance company.
8. How is the premium amount calculated for a mediclaim policy?
The premium amount for a mediclaim policy is based on various factors like age of the eldest family member, policy term, coverage type, sum insured chosen, location of the insured, number of members in a policy, etc. Most of the top insurers have premium calculators in their websites to help customers know their charges. You can also get a premium quote by entering in your personal details like name and phone number.
9. How much sum insured do I need in a mediclaim policy?
Choosing the sum insured amount is entirely based on your personal choice. If you have a family history of medical conditions, it is better to have a higher sum insured amount. For individuals, a sum insured amount of Rs.2 lakh to Rs.3 lakh could be adequate in most cases. For families, it is better to have a floater cover with sum insured over Rs.5 lakh.
10. Is there any grace period for renewing my mediclaim policy?
It is always better to renew a policy before the date of expiry. However, if it is not renewed by that date, there is a grace period of 15 days before the policy lapses. There will not be any coverage for the days for which the premium is not renewed.
11. What is the best mediclaim policy for senior citizens?
There are some health insurance companies that offer policies designed exclusively for senior citizens in the country. Some of the top policies in the market include:
12. Can I use my mediclaim policy to get LASIK surgery?
Mediclaim policies provide coverage only for general ailments and emergency treatments. LASIK is a cosmetic procedure, and it will not be covered by a mediclaim policy.
13. What is overseas mediclaim policy?
An overseas mediclaim policy provides coverage for any illnesses or accidents occuring in foreign soil. This is not a common feature in most mediclaim policies available in the market. Very few companies offer this type of insurance. If you are a frequent overseas traveller, you must consider choosing a policy that offers this benefit.
14. How many claims can I make in one year?
You can make any number of claims within the limit of your sum insured amount. If you have a family floater policy, you can make claims for more than one covered member during a particular policy year.
15. Can I get coverage for dental treatment?
Dental treatment is also considered to be a cosmetic treatment by most medical insurance companies. Hence, dental coverage is not a standard thing in a mediclaim policy. However, this does not apply for dental issues arising out of accidents. Any dental surgery necessitated by an accident will be covered by a mediclaim policy.
16. Can I transfer my mediclaim policy to another insurance company?
Yes. This feature is called portability. As per the IRDAI regulations, portability feature is a must for all insurance service providers. If you come across a better policy cover while already subscribed to a mediclaim policy, you can transfer this cover to the other service provider. This can be done only at the time of renewal. The existing service provider must be notified about this change at least 45 days in advance.
17. Will I lose my accumulated benefits if I transfer the policy to another insurer?
No. You will not lose out on any accumulated benefits if you transfer your policy to another insurance company. Benefits like no claim bonus, renewal credits for pre-existing conditions, etc. can also be transferred during portability.
18. Till what age can I renew my mediclaim policy?
Insurance companies set forth specific eligibility criteria with respect to the entry age of the policyholder. There is no exit age in most mediclaim policies as long as the renewal premium is paid on time. A few insurance companies cap the maximum age of availability to a specific limit, but this is no longer a common thing. Lifelong renewability option is now available with most insurers.
19. What are the common add-on policies available with mediclaim policies?
Most insurance companies offer plenty of add-on (rider) policies to enhance the coverage offered. These policies can be bought by paying a little extra premium amount. Some of common riders available with mediclaim policies include:
Mental health professionals have hailed the Insurance Regulatory and Development Authority of India (IRDAI’s) recent notification, in which the insurance regulator asked all health insurance providers to also offer coverage for mental illnesses and disorders. Mental health experts are of the opinion that this move will enable adults and children with mental disorders to avail affordable treatment.
The notification, which was issued by Mr. DVS Ramesh, General Manager, Health (Insurance Regulatory and Development Authority of India), to all insurance companies in India states that insurance providers have to provide insurance coverage for the treatment of various mental illnesses, given that the Mental Healthcare Act came into force on 29 May 2018.
21 August 2018
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