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Mediclaim Policy

A mediclaim is an insurance plan that recompenses your hospitalization expenses incurred on the treatment of an illness or an accident. It also offers cashless treatment in some of the best hospitals in India as well as abroad.

In the event of reimbursement through mediclaim policy, an insured person needs to provide the relevant medical bills of the hospitalization to the insurance provider. However, in the case of cashless hospitalization, the insurance provider directly deals with the hospital for the settlement of the bills.

Difference between Mediclaim and Health Insurance?

Even though mediclaim insurance and health insurance are often used interchangeably, both are slightly different. On one hand where mediclaim provide cover against hospitalization and treatment incurred due to illness or accident up to the sum insured selected by the policyholder.

On the other hand, health insurance policies are more comprehensive in terms of coverage they provide and have a flexible nature.

To understand the difference between these two types of insurance policies, go through the below-mentioned table:

Mediclaim Insurance Health Insurance6
This policy works on the principle of indemnity. The hospitalization expenses according to the sum insured are reimbursed to the insured. A health insurance policy works on the principle of benefit. Therefore, when an insured meets with some eventuality, a lump sum amount is paid to him/her. Few examples that clearly presents the benefits of health insurance are – riders for critical illnesses, policies related to personal accidents.
An insured can claim an unlimited number of claims during the tenure of the policy until the sum insured gets exhausted. If an insured encounters an accident that results in disability or death, or is diagnosed with some illness that is critical, then lump sum amount is given. Moreover, the cover is ceased to exit.
Generally, These policies cover the hospitalization expenses only. Therefore, to get a refund, one has to be hospitalized. The health insurance policies are more flexible, on the other hand. With hospitalization expenses, they cover the cost of the ambulance,  loss of income because of the illness, and some policies as well as offer daily cash allowance. If an insured has taken a rider, then he/she is exposed to get more extensive coverage.
The sum insured covered in a policy is most of the times is lesser than a health insurance policy. An insured gets a larger sum insured in his/her health insurance policy. Some health insurance plans even provide cover of up to Rs1 Crore.
The premiums that one pays against his/her mediclaim policy get tax rebates under the section 80D of Income Tax Act, 1961. Health insurance policies also provide tax benefits under the section 80D of Income Tax Act, 1961.

Benefits of Mediclaim Policy in India

  • It is an affordable way to get the adequate healthcare services.
  • It wears off lots of worries related to medical treatment expenses in case of sudden illness or accident resulting in hospitalization.
  • With mediclaim , an insured can get the cashless hospital facility, wherein an insured need not pay upfront for the medical expenses incurred in the hospitalization. The insurance provider settles the payment of the treatment received at any of the network hospitals.
  • An individual who has taken  policy and pays its premiums avails tax benefits under section 80D of Income Tax Act, 1961 for up to Rs.15, 000. A mediclaim insurance policy taken for parents who are senior citizens gets a tax benefit for up to Rs.20, 000.

Inclusions: What is covered

Even though an insurance policy offers really useful medical benefits, but the inclusions or the insurance coverage offered depends upon the health insurance company. Some of the common inclusions that best mediclaim policies in India cover are:

  • Hospitalization Expenses: All the direct medical expenses incurred in the hospitalization such as Operation Theater (OT) charges, expenses of oxygen, medicine, x-ray, diagnostic material, radiotherapy, chemotherapy, expenses of the donor in case of organ transplant, pacemaker, etc. are covered.
  • Post and Pre-Hospitalization Expenses: The medical expenses incurred 30 days before the hospitalization and 60 days after the hospitalization are covered. Some medical insurance policies even provide assistance for availing the services like an ambulance.
  • Day-Care Medical Treatment: Some specific technology treatments do not require 24-hours of hospitalization, but some policies cover them as well.
  • Fees of Medical Professional: The charges for visiting doctors, fees of the nurses, charges of anesthesia, etc. are covered in some  policies.
  • Charges for Accommodation in the Hospital: The accommodation charges of the regular ward or ICU are covered with cashless hospitalization.
  • Charges of Investigation are covered: Some policies as well cover the charges of the investigation.

Read More- Health insurance for parents Above 50 Years

Exclusions: What is not covered

The exclusions of an insurance plan differ with the insurance providers. However, some generic cases and scenarios that most of the insurers include in their list of exclusions of mediclaim policy are:

  • The cost of hearing aids, contact lenses, and spectacles are not included.
  • All the pre-existing medical conditions and diseases that the policyholder has been suffering from before the mediclaim insurance comes in force are not covered.
  • All the medical conditions or disease (unless they are specified in the policy document) that occur within 30 days of the commencement of the policy are also not covered.
  • Anaesthetic or cosmetic treatments and plastic surgeries are not covered.
  • Medical conditions or injuries caused due to war or war-like operation, or foreign invasion.
  • Any kind of dental surgery or treatment is not covered. However, if a dental treatment arises due to the accident and needs hospitalization that can be covered.
  • Naturopathy treatment
  • Childbirth, pregnancy, abortion, miscarriage, C-section, or any other complication related to pregnancy is not covered.
  • Lab tests, x-ray, or other medical expenses incurred in the direct relationship with any treatment.
  • Intentional injury to self.
  • Sexually transmitted diseases such as AIDS / HIV, or the variation of these diseases are not covered.
  • Drug or alcohol abuse.
  • Disease or injury incurred due to nuclear radiation, or exposure to nuclear materials or weapons.

How to Get the Claim Benefits of Mediclaim Insurance Policy


In case of reimbursement, it is required to inform the TPA or the insurance provider about the hospitalization as soon as possible. It is because the insurance providers and TPAs have a very specific definition of hospitalization and will not entertain the claims of the reimbursements that do not fall in their category. Moreover, it is necessary to know the list of the hospitals that are covered in the network list of hospitals of the insurance provider or TPA.

On hospitalization, an insured must keep a track on all the expenditure and must maintain the bills record. Any changes in the treatment or new treatment plan must be sent to the insurance provider for approval. For example, if an insured is submitted for treatment of broken leg, and suddenly encounters a headache, for the reimbursement of CT scan of the head or other head related treatment, he/she needs to apply a new reimbursement request.

The claim form must be filled fairly without any ambiguities and should be complete. The hospital bills must be with the insured and should be presented to the insurance provider when required. A duly filled and clean form with all the required documents helps to settle the claim easily.

Cashless Claims:

To process the cashless claim, the insured is required to fill the ‘preauthorization request form’ in detail and submit it to the mediclaim insurance company.

For Cashless Planned Hospitalization:

It is suggested to inform the insurer or TPA at least 72 hours before the planned hospitalization to get the benefits of cashless medical facilities.

For Cashless Emergency Hospitalization:

In emergency hospitalizations, such as an accident, an insured does not have time to inform the insurer or fill the ‘preauthorization form’ beforehand. Therefore, for such cases, it is suggested to provide the policy ID at the hospital that is in the network of the insurance provider and inform the insurer within 24 hours of hospitalization

Factors to Consider Before Buying a Mediclaim Policy

It is always wise to have an insurance policy that provides financial assistance in case of emergency medical situations. However, to select one policy out of many available is a difficult task. Therefore, it is suggested to keep the below-mentioned factors in mind before buying a mediclaim insurance policy in 2018:

  • Co-Payment: A policy with the option of co-payment allows an insured to pay a part of the medical expenses from his/her pocket while the rest of the part is paid by the insurance company. In this way, the option of co-payment eventually reduces the cost of the mediclaim insurance premium.
  • Coverage of the Mediclaim Insurance: It is suggested to take an adequate insurance policy to avoid insufficient medical covers. Picking up a medical policy that offers sufficient medical cover is recommended.
  • Waiting Period: Most of the insurance policies have an initial waiting period of 30-days for almost all illnesses, but for the cases of accident it allows immediate hospitalization. The cover for the pre-existing diseases usually starts after 4-years. Since the benefits of the policy cannot be availed during the waiting period, therefore, it is recommended to keep a check on the waiting period of the policy and opt for a plan with a lesser waiting period.
  • Caps on Specific Treatment: It is wise to check for the treatment specific limits before purchasing a policy.
  • Network Hospitals: Since the cashless hospitalization is provided for the network hospitals only, it is recommended to check the network hospital list.
  • Exclusions: Keeping a close eye on the policy exclusions is very important. This is to ensure whether one is not missing the feature that one wants.
  • Maternity Benefits: Most of the mediclaim policies do not cover maternity related issues or provide maternity medical benefits. Therefore, to get the same, it is suggested to look up for the health insurance plan that covers the maternity benefits. However, one can avail this benefit as an add-on cover with the basic mediclaim insurance plan.
  • Free-look Period: It is always good to go through the terms and conditions (policy term) of the policy while the policy is under the free-look period. The free-look period provides an opportunity to return the mediclaim policy and get back the paid premiums after some deductions.

Why Compare Mediclaim Insurance Policies in India?

It must be noted that mediclaim insurance is not an alternative to the health insurance as the features and benefits that a health insurance policy provides are not covered in a mediclaim.

However, before buying a mediclaim plan, it is suggested to compare policies provided by various insurance providers online. The parameters that can be considered for comparing the features of policies are- claim settlement ratio, premium cost, coverage offered, features etc.

There are some reliable insurance web aggregators that aid the insurance seekers with the much-needed mediclaim plans. They provide the best results according to the insurance needs of the individual and help one to decide on an affordable and best plan.

Parameters to Choose a Right Policy

Choosing one of the most affordable and right mediclaim policy is one of the tedious task as one has to go through an extensive range of providers and select one. However, if one keeps the following parameters in mind, One can choose the best mediclaim policy online very easily:

  • The claim settlement ratio
  • Sum assured and policy inclusions
  • The sub-limits of different expenditures
  • Are the maternity benefits covered, if they are required?
  • The option of single and regular premiums, so that one can select an option accordingly
  • Good customer support service of an insurance provider is one of the deciding factors of its services.
  • Consider the hidden clauses related to reimbursement and cashless claims at the time of purchasing a plan to avoid future inconveniences.
  • Policy renewal age

Mediclaim Policy FAQs

Q1. What is the process to get the most suitable mediclaim policy for me?

A1. Since there are many health insurance providers available online, it may become difficult for a person to select the best policy. If you are one of them and are unable to select the most suitable mediclaim insurance plan for yourself or your family, it is suggested to visit an insurance web aggregator website. Here, you can compare health insurance policies from top health insurance providers and select the most suitable one for you.

Q2. Can I port a mediclaim policy? If yes, then how?

A2. Portability of mediclaim policy allows an insured to switch from one existing insurance provider to another at the time when policy needs to be renewed. So, yes, one can port a policy easily. However, only similar policies can be ported, such as policy with basic reimbursement can only be ported to basic reimbursement policy only. A policyholder needs to submit the request to port a policy at least 45 days before the expiration date of the existing policy.

Q3. How to calculate the premium of a mediclaim insurance policy?

A3. Generally,  most of the insurance providers offer the facility of online mediclaim premium calculator. All you need to do is to provide certain details like sum insured, number of the insured members, etc. to calculate premium through the online calculator.

Q4. What are the eligibility criteria to get a mediclaim insurance policy?

A4. Anyone who comes under the age group of 18 years to 65 years is eligible to get a mediclaim policy. Children below the age of 18 years can also be covered in a mediclaim policy if his/her parents are covered under the payment of the needed premium.

Q5. What are the mediclaim policies for employees in India?

A5. To provide a friendly working atmosphere for its employees and retain the talent, the employers in India provide a group mediclaim insurance policy to its employees. If an employee wants he/she can include family members in the mediclaim. A person having mediclaim insurance policy also gets tax benefits under section 80D of the Income Tax Act, 1961.

Q6. What is family floater mediclaim plan?

A6. In a family floater plan, the sum insured is shared among the members of the family who are covered. Generally, cover for self, spouse, children (some policies cover 2 or some 4), and dependent parents is provided in one mediclaim family floater plan. These members can opt for any number of claims during policy tenure but under the limit of the sum insured.

Q7. Explain cashless mediclaim insurance

A7. In a cashless mediclaim insurance policy, all the medical expenses incurred in a network hospital are paid directly by the insurance provider. However, the sum insured is always taken into consideration and cashless hospitalization is entertained only in the network hospitals.

Q8. What is included in group mediclaim insurance policy?

A8. A group mediclaim insurance policy protects all the employees of a company and their beneficiaries against a medical emergency that needs domiciliary care or hospitalization during the term of the policy.

Q9. What is covered in overseas mediclaim policy?

A9. To get medical expenses cover against sudden illness or/ an accident while traveling overseas, this mediclaim insurance policy is ideal. Generally, a normal mediclaim insurance policy does not cover overseas medical expenses, and to get a medical treatment even in case of emergency is exorbitant. Therefore, it is suggested to have an overseas mediclaim policy.

Q10. What is individual mediclaim insurance?

A10. A mediclaim insurance policy that provides medical cover only to one person in case of domiciliary care or hospitalization is known as individual mediclaim.  

Q11. Does a mediclaim policy cover pre-existing diseases?

A11. Even though some insurance policies offer medical cover for pre-existing disease, but have a minimum of 3 to 4 years of the waiting period. However, group mediclaim policies start covering pre-existing diseases from day one. Some of the group mediclaim policies that cover pre-existing disease are:

  • Silver Health by Bajaj Allianz
  • Red Carpet Health Insurance Policy for the senior citizens from Allied Insurance and Star Health
  • SBI Life Smart Health Insurance

Q12. Do mediclaim policies cover dental treatments?

A12. Generally, dental treatments are not covered by mediclaim policies in India, However, if the dental injury is caused due to an accident and required hospitalization then the expenses will be covered.