Mediclaim Policy

What Is Mediclaim Insurance? A Mediclaim Insurance is a type of health insurance plan that shields you against emergency hospitalisation expenses due to accidents and specific diseases. It helps you remain financially secured in times of unexpected medical expenses. However, the insurance coverage is limited to the sum insured opted under the plan.

Features of Cashless Mediclaim Insurance Policy

A mediclaim insurance policy comes with the following features -

  • 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.

  • 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.

  • 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.

Types of Cashless Mediclaim Policies

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

  • Hospitalisation Plans: Also known as indemnity plans, hospitalisation plans shield you against expenses arising due to hospitalisation. In case you get hospitalised, the insurance company will pay for several expenses including cost of medicines, nursing, boarding, room rent expenses, ICU/ICCU expenses, etc. There are two types of hospitalisation plans, viz., individual plans and family floater plans. Individual plans offer cover to individuals whereas family floater plans cover family members under a single policy.

  • 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.

  • 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.

  • 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.

  1. 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 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.

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 majorly 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: 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.

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Health Insurance Cashless Mediclaim FAQs

  • 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.

  • In how many ways can cashless treatment be availed?

    Cashless treatment can be availed in two ways: planned hospitalization and emergency hospitalization. In planned hospitalization, you need to inform the insurer about the hospitalization 24 hours in advance. In emergency hospitalization, you need to inform the insurer 24 hours after being hospitalized. The timing in both cases can vary from insurer to insurer.

    It is advisable to read the policy wording to understand the cashless mediclaim facility in your policy. Or give us a call at our toll-free number 7551196989. Our experts will help you file a claim for cashless treatment as well as answer your questions related to health insurance.

  • Will I be required to pay anything at the hospital in spite of having a cashless mediclaim facility?

    Yes. There are certain expenses that health insurance plans may not always cover you for. You are required to pay for these expenses from your own pocket even if you have a cashless mediclaim facility. These include the following: 

    • Expenses related to registration/admission
    • Expenses related to attendant/visitor pass
    • Special nursing charges that are not authorized by the attending doctor
    • Service charges that are not a part of the room rent
    • Charges related tor extra bed for attendant
    • Bed retaining charges
    • Charges for laundry, television, telephone, fax charges, etc.
    • Cost related to toiletries, food, and beverages for attendants and visitors, etc.
    • Expenses on medicines that are not related to the treatment
    • Stationery, xerox or certifying expenses

    Note that the list is only indicative and not exhaustive. Also, it may vary from insurer to insurer.

  • What happens if my cashless health insurance policy lapses during hospitalisation?

    In case your cashless health insurance policy lapse during hospitalisation, but you were already hospitalised before the policy expiry date and had informed the insurer, then the insurer will honor the claims as per the terms and conditions of the policy.

    If hospitalisation occurs after the policy lapses or during the grace period, then the insurer is not expected to admit the claim going by the prevailing rules. But it is best to inform the insurance company immediately on hospitalisation as the claim will be settled according to the circumstances of the case.

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