Cashless Mediclaim Policy

A cashless mediclaim policy helps you stay stress-free even in difficult times. If covered under a cashless mediclaim policy, you will not be required to pay anything if the treatment availed is covered under the policy. The expenses will directly be paid at the hospital by the insurance company.

Mediclaim policy is a viable option to safeguard yourself against the soaring healthcare expenses, arising because of hospitalisation due to an illness or accident, without needing to incur any expenses from your own pocket.

This simply means that insurance providers have tie-ups with several hospitals all over the nation which are known as ‘network hospitals’ to offer cashless facilities to their policyholders. All the medical bills will directly get settled by the insurance company with the hospital upon availing of treatment at one of the network hospitals.

During any medical emergency, a cashless mediclaim policy acts as a blessing as it ensures you get complete financial protection and peace of mind. In comparison to, reimbursement mediclaim policy, wherein you are required to pay medical bills first and later get it reimbursed from your insurance provider, a cashless Mediclaim highly beneficial in the event of a healthcare emergency.

Features of Cashless Mediclaim Insurance Policy

A mediclaim insurance policy comes with the following features -

1. Coverage

A mediclaim provides coverage for hospitalisation expenses as well as medical treatment expenses incurred due to any accident or pre-defined illness subject to the plan’s sum assured.

2. Number of Members Covered

Under a mediclaim, you have an option to include your family members including spouse, dependent children, parents, and parents in law, in addition to you.

3. Claim Process

You can make a cashless claim under a mediclaim policy by getting the medical treatment at one of the partner hospitals of the insurance provider.

4. Ease of Cashless Hospitalisation

Insurance companies offering health insurance plans to the customers have tie-ups with hospitals wherein the insured can avail treatment without paying anything for the expenses that are covered under the policy. These hospitals are known as network hospitals. If you are covered under a cashless mediclaim policy, then you can avail of this benefit.

5. Ease of Buying Policy Online

It is easy to buy a mediclaim policy online. At InsuranceDekho, all you need to do is land on the health insurance page, fill in details as asked, and compare and shortlist from the best mediclaim plans offered by different health insurance companies, as per your budget and other requirements.

Types of Cashless Mediclaim Policies

You can choose any of the following types of cashless mediclaim policy as per your requirements -

1. Senior Citizen Mediclaim Policy: Senior citizen mediclaim plans cover people aged above 60 years of age. These plans are especially designed for parents and senior citizens keeping in mind their coverage requirements.

2. Individual Mediclaim Plan: Under individual mediclaim policy, only one person can be covered, i.e. the policyholder. Family Floater Mediclaim Plan: As the name suggests, under family floater mediclaim plan, one can cover their family members as well apart from themselves. These may include their spouses, dependent parents, dependent children, grandparents, etc.

3. Hospital Daily Cash Benefit Policy: Under this policy, the insurance provider pays you a fixed amount for each day when you get hospitalised, irrespective of the actual expenses incurred.

4. Critical Illness Plans: These plans cover you for specific critical illnesses, as specified under the policy. Once diagnosed, the insurance company pays you a lump sum amount that you can use to avail treatment, pay off debts, or even compensate for the lost income.

5. Personal Accident Plans: Personal accident mediclaim policy protects you for healthcare expenses arising due to an accident. For instance, impairment, mutilation, other bodily injuries, or even death.

How Can I Make A Cashless Claim Under My Mediclaim Policy?

Cashless mediclaim treatment can be availed in both the following cases -

1. Planned Hospitalisation

In the case of planned treatment, you need to intimate the insurance company about the hospitalisation before getting hospitalised. On reaching the hospital, you will have to fill the pre-authorization form and submit it to the TPA. Your form will then be checked and verified by the TPA service provider. On approval, the insurance company facilitates cashless treatment to you by paying hospital expenses and other expenses related to the treatment. This way, you can avail of cashless treatment as per the terms and conditions mentioned in the policy.

2. Emergency Hospitalisation

In the case of an emergency, the pre-authorization form must be filed within 24 hours of hospitalisation by one of your relatives. Your request will then be processed within 6 hours by the TPA. Post-approval, the insurance company will settle the hospitalisation expenses directly at the hospital.

Benefits of Cashless Mediclaim Plans

Cashless mediclaim plans have several advantages. Some of them are as follows:

  • Ease of Buying: Cashless mediclaim plans can be purchased offline as well as online at InsuranceDekho or from the website of health insurance companies. The purchase process is simple and takes just a few minutes to get a policy.

  • Tax Benefits: The premium paid for mediclaim plans qualify for tax deductions for up to Rs. 25,000 under Section 80D of the Income Tax Act, 1961. These plans also offer an additional tax benefit of Rs. 25,000 premium paid for parents’ mediclaim policy (Rs. 50,000 if parents are senior citizens).
  • Cost-Effective Healthcare Services: Under cashless mediclaim plans, you can avail of cost-effective healthcare services at premium hospitals.

Difference between Mediclaim Insurance and Health Insurance

To understand the difference between mediclaim insurance and health insurance, refer to the table below:

Basis

Mediclaim

Health Insurance

Coverage Benefits

A mediclaim policy covers the insured for hospitalisation expenses, pre-existing diseases, as well as expenses related to treatment required due to accidents, for a specific sum insured.

A health insurance plan offers comprehensive coverage including pre-hospitalisation expenses, post-hospitalisation expenses, ambulance expenses, daycare expenses, etc. It also protects you in the event of an accident.

Add-on Benefits

A mediclaim policy does not offer any add-on cover except hospital cash.

A health insurance policy comes with several add-on covers for added coverage such as critical illness cover, maternity cover, daily hospital cash benefit, etc.

Flexibility

There is a limited scope of flexibility under a mediclaim due to the absence of rider benefits.

A health insurance plan offers you substantial flexibility in terms of coverage as well as premium payment.

Sum Insured

Sum insured under a mediclaim policy usually does not exceed Rs. 5 Lakh.

Health insurance plans offer extensive coverage. Hence, the sum insured may even go up to Rs. 6 Crore under some plans.

Hospitalisation

Hospitalisation is required for making a claim.

Health insurance plans cover daycare procedures, and hence, hospitalisation for at least 24 hours is not necessary for all claims.

Claim Rejection Reasons in Cashless Mediclaim Policy

There are several reasons due to which cashless insurance claims can get rejected. However, some of these reasons can be avoided if you follow a little extra care. Here are reasons for cashless claim rejection:

1. Pre-Existing Conditions: One of the major reasons behind cashless claim rejection is Pre-existing health conditions. For a specific time period, which may differ from 24 months to 48 months depending upon the insurance company to the insurance company, pre-existing health conditions during the time of policy issuance are not covered. This time period is referred to as the waiting period, and during this duration, the hospital expenses incurred due to treatment of pre-existing conditions are not covered under the cashless Mediclaim plan.

2. Unaware About the Claim Process: At times being unaware of the entire claim procedure and not being able to follow the process diligently results in claim rejection. For instance, by missing the proper time limit for claim filing can become one of the reasons for your claim getting rejected.By mentioning wrong details in the form, non-submission of correct documents, etc could result in cashless claim rejection. However, if you know the claim process well and take assistance from the customer support team of your insurance company for any details, it can help you in reducing these types of claim rejection.

3. Exclusions: Although, a cashless Mediclaim policy offers coverage for all the major hospitalisation expenses yet these policies come with some exclusions. For instance, hospital expenses incurred due to treatment of sexually transmitted disease, HIV/AIDS are not offered coverage under the cashless Mediclaim policy. For all the expenses that are excluded from the policy, you can raise a claim. In case, you raise a claim for one of the exclusions, then it will result in straight away rejection of the claim.

4. Non-Disclosure of Material Facts and Information: In case, you hold back any material facts or information while purchasing a cashless Mediclaim policy, then it can result in the rejection of claim at a later stage. For instance, if you do not disclose the information regarding any pre-existing health condition at the time of buying a cashless mediclaim policy can become one of the reasons behind your claim getting rejected later.

5. Policy Period: A cashless Mediclaim policy offers an insurance contract for a certain time period known as the policy period. After the expiry of the insurance policy, all the benefits and coverage offered under the policy stands invalid. In case, you register for any claim after the expiry of your cashless mediclaim policy period and before getting it renewed, it would result in claim rejection.

Things to Consider When Buying Cashless Mediclaim Policy in India

If you are planning to buy health insurance anytime soon, then you must consider the following things:

  • Sum Insured: Sum insured refers to the total coverage amount that you can get under a mediclaim policy. The premium that you pay for the plan significantly depends on the sum insured. Thus, you should opt for an optimum sum insured considering your medical requirements and your budget.
  • Type of Mediclaim Plan: There are major 4 types of mediclaim policies namely hospitalisation plan, hospital daily cash benefit plan, critical illness plan, and personal accident plan. You must choose the type of plan which best meets your requirements.
  • Co-Payment Clause: The co-payment clause refers to the clause wherein you agree to share a part of the incurred expenses with the insurance company. Thus, while choosing a mediclaim, you must check if you want to opt for a co-payment clause or not. The co-payment clause helps you get the plan for a lower premium but if chosen also reduces the sum insured amount at the time of claim settlement.
  • Network Hospitals: Network hospitals refer to the partner hospitals of the insurance company at which you can avail cashless treatment. Thus, while selecting a mediclaim policy, you must choose an insurance provider which has a wide network of partner hospitals.
  • Waiting Period: Mediclaim plans come with waiting periods, before which you cannot avail of coverage benefits under the policy. Also, there are specific waiting periods for pre-existing diseases or illnesses. Thus, you must check for these waiting periods before buying a mediclaim policy.
  • Incurred Claim Ratio: Claim settlement ratio incurred by the insurance company is important to consider while purchasing a cashless mediclaim policy. Insurance providers with a high claim settlement ratio make sure that the claims raised by the policyholders get settled quickly and without much hassle.
  • Cost: Although, cashless Mediclaim policy purchasing decisions cannot be made solely taken based on the plan cost, yet higher premium rate can negatively impact your annual budget. Therefore, it is important to consider the plans that can offer you the required coverage but at an affordable rate.

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FAQ About

  • How does a cashless mediclaim policy help me?

    Cashless mediclaim helps you deal with medical emergencies by paying for your hospital bills. In a cashless mediclaim policy, all the medical bills are directly settled by the insurance company provided the amount falls within the sum insured limit. This leaves the insured tension free.

  • Can I avail of cashless treatment in any hospital?

    Every insurance company has tie-ups with hospitals that are known as network hospitals. You can avail cashless treatment only at the network hospitals. If you are hospitalised in a non-network hospital, then you will be required to pay the hospital bill out of your own pocket and later file a reimbursement claim to the insurer.

  • What all factors are responsible for affecting premiums paid towards cashless mediclaim policy?

    Premiums paid towards cashless Mediclaim insurance are dependent upon several factors. Given below is the list of some major factors that can possibly affect the premium paid towards your cashless mediclaim policy:

    • Pre-existing health conditions
    • Age
    • Self-destructive habits like drug abuse and alcohol
    • Medical history of family
    • Profession
    • Marital Status, and others
  • What is the meaning of ‘free-look period’ in cashless mediclaim policy?

    A free look period is the time period given to the new policy buyers under a cashless Mediclaim policy in order to understand and agree with the terms and conditions mentioned in the policy document. In case, they disagree with some terms and conditions mentioned in the policy, then they can terminate it without requiring to pay any penalties. Generally, most of the cashless Mediclaim policy comes with a free look period of 15 days within this duration, a policyholder can cancel the policy if they disagree without any fines or penalties. However, it is important to mention the reason for cancellation of the insurance policy.

  • Are there any available tax benefits under the cashless Mediclaim policy?

    Yes, as per the section 80D of the Income Tax Act, premiums that are paid towards cashless Mediclaim policy can be claimed as tax deductions. Premiums paid towards the insurance plans that offer coverage to self, spouse, children and parents are eligible for availing tax deductions.

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