What is Mediclaim Policy?

A mediclaim policy is one of the of health insurance plan. It was first introduced in 1985 by the General Insurance Corporation and its subsidiaries. At that time, the plan was officially called the Mediclaim Policy, which is why even today people commonly use the word mediclaim when referring to health insurance. In its original form and the mediclaim policy worked only on a reimbursement basis, meaning the customer had to pay hospital bills first and then submit documents for reimbursement. The coverage was also very basic, including only hospitalization expenses, room rent, and consumable costs with no OPD, no daycare coverage, and no cashless facility.

In 1999, after the formation of IRDAI, the cashless hospitalization system was introduced, making treatment faster and more convenient for customers. Over time, health insurance plans have expanded to include many more features, but people still widely use the mediclaim policy in everyday language to describe any health insurance plan, because of its long history in India.

Benefits of a Mediclaim Policy

Mediclaim policies offer several benefits. They are cost effective against rising medical expenses and provide financial support during medical emergencies such as accidents or sudden illnesses. Policyholders can access cashless hospitalization at network hospitals where the insurer directly settles the bill. These plans also offer tax benefits under Section 80D of the Income Tax Act, allowing deductions on premiums paid. Renewability ensures continuous protection as long as premiums are paid on time. Here are some main benefits of Mediclaim policy:

1. Avail Cashless Treatment – With a Mediclaim policy, you can avail cashless treatment across network hospitals in India. This allows you to get admitted and receive medical care without paying anything upfront from your own pocket.
2. Get Quality Treatment – Mediclaim insurance ensures timely and quality treatment at network hospitals. Since you don’t have to arrange money in advance, you can focus on getting the best medical treatment without any financial stress.
3. Instant Financial Support – During medical emergencies, arranging funds becomes difficult and stressful. With a Mediclaim policy, you can start treatment immediately without worrying about finances. The insurer takes care of the medical expenses as per the policy coverage.
4. Tax Rebate - Premiums paid towards your Mediclaim policy are eligible for tax benefits under Section 80D of the Income Tax Act. This helps you save on taxes while ensuring financial protection for health-related needs.
5. Cover Hospital Bills - A Mediclaim policy covers major hospitalization expenses such as room rent, doctor fees, ICU charges, medicines, diagnostic tests, and other medically necessary treatments. This reduces the burden of rising medical expenses.

Types of Mediclaim Policy Available in India

Several types of Mediclaim plans are available depending on individual needs. Individual Mediclaim covers only the policyholder. Family floater plans cover all family members under a shared sum insured. Group Mediclaim is offered by employers to employees. Senior citizen Mediclaim is designed for older adults with age-specific benefits. Critical illness Mediclaim covers major illnesses like cancer and kidney failure. Overseas Mediclaim provides coverage for medical treatments outside India. Low-cost Mediclaim policies are designed for economically weaker sections or small business employees requiring basic protection.

Understanding the types of Mediclaim policy is important before choosing the right plan for yourself or your family. Different people have different healthcare needs, and each type of Mediclaim insurance offers specific benefits. Here are the most common types:

1. Individual Mediclaim Policy - This type of mediclaim covers only one person. It is ideal for individuals who want personal coverage with customized benefits.
2. Family Floater Mediclaim Policy - In this type of policy, a single sum insured is shared among all family members. It is a cost-effective option for families and you will get attractive discount benefit by opting by opting family floater plan.
3. Senior Citizen Mediclaim Policy – This policy is designed for people above 60 years, this category covers age-related illnesses and medical conditions.
4. Critical Illness Mediclaim Insurance - These types of Mediclaim plans provide a lump-sum payout when diagnosed with serious illnesses like cancer, stroke, or heart disease.
5. Maternity Mediclaim Policy – A maternity mediclaim policy provides financial protection for expenses related to pregnancy, childbirth, and newborn care. It covers costs like delivery, pre- and post-natal checkups, hospitalization, helping ease the financial burden during maternity.

Each type of mediclaim policy is designed to meet different healthcare needs. Some plans focus on basic hospitalization, while others offer wider benefits like maternity or critical illness support. The best mediclaim policy for you depends on factors such as age, family size, medical history, and budget. Choosing wisely ensures better financial protection during medical emergencies.

Inclusions Under Mediclaim Policy

Mediclaim policies usually cover expenses related to hospitalization for more than 24 hours. Many insurers also offer a cumulative bonus for every year in which no claim is made:

• Hospitalization Expenses - A Mediclaim insurance plan covers medical costs when you are admitted to the hospital for more than 24 hours. This includes doctor fees, surgery charges, nursing care, and all treatment related expenses.
• Room Rent Expenses - Your health medical insurance policy includes coverage for hospital room rent whether it is a single private room, shared room or deluxe room depending on the plan. Choosing the best Mediclaim policy helps you get higher room rent limits or even no room rent capping.
• Consumable Expenses - Modern medical treatments includes one time usable things like gloves, syringes, PPE kits, masks, bandages, and etc.

Exclusions Under Mediclaim Policy

Certain treatments are not covered under Mediclaim. Pre-existing conditions are excluded until the waiting period is completed. Cosmetic procedures done for aesthetic reasons are not payable. Dental treatments are usually excluded unless caused by accidents. Expenses related to pregnancy, abortion, or maternity are not covered unless specified. Injuries caused by suicide attempts, self-harm, or sexually transmitted diseases are excluded. Vaccinations and immunizations are also outside the scope of coverage.

• Cosmetic or Plastic Surgery - Any treatment done for cosmetic purposes, beautification, or personal enhancement is not included in a mediclaim insurance plan.
• Lifestyle Related Diseases - Illness caused due to unhealthy habits like smoking, drug abuse, alcohol-related liver disease may be excluded or come with waiting periods.
• Self Inflicted Injuries or Suicide Attempts - Injuries caused intentionally or due to suicide attempts are not covered.
• Pregnancy and Related Conditions - Unless you have a separate maternity plan or add-on, pregnancy and childbirth expenses remain excluded.
• Diagnostic Tests Without Illness - Tests done without hospitalization or diagnosis are not covered.
• Injuries Due to Alcohol or Drug Abuse - Claims arising from alcohol intoxication, substance abuse, or self-harm are strictly excluded under all mediclaim policies.
• Alternative & Experimental Treatments - Treatments not recognized by medical science, unapproved therapies, or experimental procedures are not covered under a health medical insurance policy unless specified.
• War, Riots, or Hazardous Activities - Claims related to war, nuclear events, riots, or dangerous adventure sports are not payable under any mediclaim policy.

How to File a Health Insurance Claim?

1. Cashless Claim Process - The easiest and fastest way to get treatment in the insurer’s network hospitals. So here is the step:

• Get admitted to a network hospital.
• Show your policy card or policy number to the hospital TPA
• Fill the pre-authorization form.
• Hospital sends the request to insurer/TPA.
• Once approved, treatment begins.
• Insurer settles the bill directly with the hospital.

2. Reimbursement Claim Process - In this claim process you have to pay expenses from your own pocket, and after that you can claim it through your insurer by submiting below mentioned documents:

• Pay the hospital bill at the time of discharge.
• Collect all original medical documents.
• Submit a reimbursement claim form to the insurer.
• Insurer verifies documents.
• Approved amount is transferred to your bank account.

Waiting Periods in Mediclaim Policy

Waiting period refers to the duration during which certain benefits cannot be claimed. Here are some types of waiting periods:

• Initial Waiting Period - No claim is allowed for the first 30 days of policy purchase and after this period seasonable disease are covered.
• Specific Illness Waiting Period- Conditions like hernia, piles, joint replacement, cataract are covered after 2 years of waiting period.
• Pre-Existing Disease Waiting Period - Diseases like diabetes, BP, thyroid, asthma, which is policyholder have before buying the policy  are covered after 3 years of waiting period.
• Maternity Waiting Period - Applicable if the plan offers maternity benefits, and in most plan maternity have 1 to 2 years waiting period.