Mediclaim Policy

Mediclaim Policy

Due to rising medical inflation rates, Mediclaim insurance and health policies have become necessary to keep healthcare affordable for the public. A Mediclaim policy is a type of health insurance that covers diseases and hospitalization costs up to a certain amount. Mediclaim policy plans also offer tax benefits under Section 80D of the Income Tax Act of India, 1961.

What is Mediclaim?

A Mediclaim policy offers coverage against medical expenses incurred by the policyholder. Individuals can claim reimbursements for their medical bills or apply for financial assistance through cashless facilities. These policies are only effective for a certain time, after which the policyholder must renew it to continue receiving benefits.

Benefits of Having a Mediclaim Policy

Some benefits of having a Mediclaim policy include:

  • You can choose to include your family members along with yourself under a single Mediclaim insurance.
  • Mediclaim policy plans can be easily purchased online through the official websites of an insurance company like Max Life Insurance.
  • Mediclaim plans are eligible for tax exemption under Section 80D of the Income Tax Act of India, 1961.
  • These insurance policies ensure cashless hospitalization.
  • As a Mediclaim policyholder, you will be eligible to avail cost-effective medical services.
  • You would not have to worry about hospital bills as the insurance company would take care of the expenses.

What are the Tax Benefits of a Medical Insurance?

Under Section 80D of the Income Tax Act of India, 1961, you can claim deductions for medical insurance premiums paid for self, your spouse, dependents, children, and parents. Section 80D operates in three ways in this regard:

  • Section 80D allows you to deduct ₹25,000 for insurance for yourself, your spouse, and your dependent children. If your parents are under 60 years old, you can deduct an extra Rs 25,000 for their insurance, bringing the total deduction to ₹50,000.
  • The deduction amount is ₹50,000 if the parents are over the age of 60. In this situation, you can claim a total deduction of ₹75,000, of which ₹25,000 is for you, spouse, and dependent children and ₹50,000 is for senior citizen parents’ premiums.
  • If both, the taxpayer and parents, are over the age of 60, the maximum deduction available goes up to ₹1 Lakh (₹50,000 + ₹50,000)

Types of Mediclaim Policies in India

1. Individual Mediclaim Policy

A single person is protected for a set sum in an individual mediclaim insurance. This coverage only covers one person for mediclaim and other hospitalization benefits. When needed, the insured individual can claim the entire sum insured.

2. Family-floater Mediclaim Policy 

In the case of a family-floater mediclaim policy, the entire family is covered for a certain amount. This covers you, your spouse, your dependent children, and, in most situations, your dependent parents. The insured amount can either be used by the entire family or a single family member.

3. Senior Citizen Mediclaim Policy 

The senior citizen mediclaim policy is an important insurance plan for the elderly. If you are intending to retire or are nearing retirement age, you may have to rely on a pension or interest on savings. In the event of an emergency, you may find yourself in a financial bind. To avert such a situation, a senior citizen mediclaim policy is recommended.

4. Critical Illness Mediclaim Policy

When a person is diagnosed with a critical illness/disease covered by the insurance, the sum insured is paid to the policyholder in a lump sum. The insured can then plan the rest of the therapy accordingly. A basic mediclaim insurance policy will only cover hospitalization costs; however, a critical illness mediclaim policy would cover all ailments that affect your career and lifestyle. In comparison to other policies, critical illness mediclaim insurance normally provides a larger claimable sum. It encompasses the following ailments:

  • Kidney failure
  • Cancer
  • Heart attack
  • Paralysis
  • Major organ transplant
  • Stroke
  • Aorta graft surgery
  • Coronary artery bypass surgery
  • Primary pulmonary arterial hypertension
  • Multiple sclerosis

5. Group Mediclaim Policy 

This is a form of insurance policy in which an employer or person in charge of a group of people wants to include cashless hospitalization or reimbursement on hospitalization expenses to their salary.

Factors to Consider While Buying a Mediclaim Policy

1. Age Criteria

Age is an important factor to consider whenever buying any kind of insurance policy. While purchasing a mediclaim policy, be mindful of the age of the family members being insured, as the final cost of the premium for a family-floater policy would depend on the age of the eldest member insured.

2. Best Combination of Premium and Coverage

While you may be tempted to buy a policy that fits your budget right away, it is vital to ensure that you are getting an extensive coverage at a premium you can pay.

3. Waiting Period Clause 

Insurers do not accept any claims during the waiting period. This waiting period applies to any pre-existing illnesses. It is also applicable to certain specific illnesses and treatments like arthritis, cataract, etc. Hence, it is important that you pick a plan with a minimum waiting period so that you can claim the benefits in case of any emergency.

4. Cashless Hospitalization Benefits

In most cases, insurance companies provide a network of hospitals where you can receive cashless treatment in the event of a medical emergency. It saves policyholders the time and effort of filling out forms at the time of admission and claim.

5. Pre and Post Hospitalization Coverage

Most mediclaim insurance policies cover hospitalization-related medical expenses. Purchase a plan that covers expenses both before and after the hospitalization to avoid paying for ambulance services, medical tests, drugs, and doctor fees, among other things.

6. No-Claim-Bonus/Discount

Insurance companies offer No-Claim-Bonus for all the years that you do not file for a claim. For all the claim-free years, the coverage amount of the policy is increased at the time of renewal.

7. Preventive Health Checkup Facility 

The cost of preventive health checkups has significantly gone up. Hence, it is best practice to check the coverage limit of preventive health checkups before signing up for the mediclaim policy.

8. Co-payment Clause 

Co-payment clause refers to the percentage of the amount that you would be required to pay at the time of claiming your policy, while the rest would be paid by the insurer. So before buying a mediclaim policy, check it there is such a clause that would impact your claim amount.

How Does Medical Insurance Work? 

  • Choose a mediclaim health insurance plan that considers your age, medical history, and other factors when determining your needs.
  • A policyholder obtains coverage in the form of an amount insured from an insurance company in exchange for his or her premiums. After the terms and conditions are finalized, you will be provided with a policy. Each policy comes with an initial waiting period (a few weeks or a month).
  • You can claim a mediclaim health insurance in two ways: cashless or reimbursement. You must seek medical care exclusively in the insurance company's network hospitals under the cashless scheme. However, as part of the reimbursement process, you must first pay all medical costs before submitting them to the insurance company for money to be paid to your account. You will not have to worry about burning a hole in your pocket to get the therapy you need in any situation.
  • Renewal and Policy Lapse — The type of plan you select determines the length of your health insurance policy. However, if you fail to renew your medical insurance policy in time, it will lapse. If your insurance has lapsed, the insurer will provide you a 6-month grace period to settle any outstanding premiums and reinstatement expenses.

Comparison Between Mediclaim Policy and Health Insurance

Feature

Mediclaim Policy

Health Insurance

Coverage

Covers medical expenses and hospitalization costs.

Covers hospitalization costs along with additional costs, ambulance charges, daily allowances, etc.

Claim

Policyholders can make multiple claims until the total sum insured is exhausted.

Policyholders are given a lump sum amount in the event of an accident, or a diagnosis of critical illness.

The policy is dissolved after the payout is made.

Cover Amount

Coverage amount is limited based on the plan chosen.

Health insurance covers can go up high if required.

Comparison Between Mediclaim Policy and Critical Illness Insurance Plans

Features

Mediclaim Policy

Critical Illness Insurance

Coverage

Covers medical expenses and hospitalization costs for various illnesses.

- Covers critical illnesses from a specified list.

- It also covers temporary travel & boarding expenses, postoperative care and loss of pay.

Benefits

- Reimbursement/cashless payment of hospital bills.

- Claims can be made until entire amount is exhausted.

Policyholder receives a tax-free lump sum after diagnosis.

Waiting Period

30 days to 1 year

Up to 3 months

Mediclaim Policy Coverage & Exclusions

Inclusions in Mediclaim

  • In-Patient Hospitalization — It covers the costs incurred if the covered individual is admitted to the hospital for longer than 24 hours.
  • Day Care Treatments - The Mediclaim policy will cover treatments that do not require hospitalization.
  • Pre- And Post-Hospitalization Coverage - Medical expenses paid before and after admission to the hospital are reimbursed.
  • Domiciliary Hospitalization - When there aren't enough hospital beds or the insured can't be transferred to one, domiciliary treatment is offered at home.
  • Preventive Health Checkups - Almost all health insurance policies include free preventative health tests once every one to four claim-free policy years.

Exclusions in Mediclaim

  • Pre-existing Medical Conditions – Most mediclaim plans do not include pre-existing medical conditions like diabetes, blood pressure, etc., until the end of the waiting period. While the waiting period for most policies is 30 days, in case of pre-existing medical conditions, it can stretch to a year or more.
  • Alternative Treatments – Mediclaim health insurance plans do not cover alternative treatments like homeopathy, acupuncture, yoga, etc.
  • Cosmetic Surgeries – Any form of treatment like plastic surgery for enhancing the looks of an individual is excluded from mediclaim plans. However, hospitalization for cosmetic treatment following an injury or accident may be covered.
  • Transmission-related Diseases – Any transmission-related diseases like HIV and AIDS are permanent exclusions from all mediclaim health insurance plans.
  • Congenital Disorders – Most mediclaim policies in India do not offer coverage for genetic disorders and medical conditions present from the time of birth.

Documents Required While Buying a Mediclaim Policy 

  • Age proof (Birth certificate, class 10th and 12th marksheets, PAN cards, etc.)
  • Address proof (Aadhar card, passport, utility bills, etc.)
  • Identity proof (Aadhar card, voter’s ID, PAN card, etc.)
  • Passport size photograph
  • Medical reports

Cashless Claim Procedure for Mediclaim Policy

In the event of a planned hospitalization, policyholders are required to submit a pre-authorization form along with the medical card in advance. In the event of an emergency medical treatment, the policyholder can present the insurance company's medical card to receive cashless hospitalization at any network hospital and then complete the pre-authorization form within the time limit.

Reimbursement Claim Procedure for Mediclaim Policy

If you are filing for a reimbursement claim, you will need to notify your mediclaim health insurance company about a medical emergency or hospitalization that is coming up soon, or within a certain amount of time once it has happened.

It is critical to maintain track of all medical bills and expenses incurred while in the hospital. You must produce all the payment receipts for medical bills to get reimbursed for your charges. It is vital to maintain all original medical invoices and payment receipts to submit them to your insurance company for reimbursement.

FAQs 

Q. Can I cancel my mediclaim policy and if yes will I get my premium back?

Many insurance companies offer a 15-30 day free-look period. If you cancel the policy during this time, you can receive up to 100% of your premium back. However, if you cancel after the free-look period, you will only receive part of your premium. No premium will be received if the policy is cancelled after 6 months of the start date.

Q. How to choose a Mediclaim Policy?

Here is how you can pick a mediclaim policy in India:

  • Look for the right coverage plan.
  • Be mindful of our budget.
  • Go for a family plan instead of an individual plan.
  • Pick a plan with lifetime renewability.
  • Always remember to compare costs and coverage offerings.
  • Always check if your nearby hospitals are part of the network.
  • Check if your insurer has a high claim settlement ratio.

Q. What are the types of cashless mediclaim?

There are three main types of cashless Mediclaim plans:

  • Cashless individual health insurance
  • Cashless family health insurance
  • Cashless senior citizen health insurance

Q. What is a mediclaim policy for employees?

Mediclaim policies are an essential part of employee benefit programs. A mediclaim policy for employees is a group insurance plan paid for by the employer. While some employers may offer it for free, others might deduct the amount from the employee’s CTC premium amount.

Q. Which mediclaim policy covers pregnancy in India?

Many group mediclaim insurance policies offer maternity covers as a part of the coverage plan. The mediclaim maternity plans cover expenses like hospitalization charges, pre-and post-hospitalization charges, consultation charges, etc.

Q: Does mediclaim cover accidents?

Yes, several mediclaim health insurance plans offer coverage for accident-related treatment and hospitalization charges.

Q: Does a mediclaim policy cover coronavirus?

Yes, there are certain mediclaim health insurance plans available that cover the costs for hospitalization due to any injuries or illnesses, including Coronavirus.

Q: How do I claim the benefits of my mediclaim policy?

There are two ways to claim benefits for your mediclaim policy –

Cashless Mediclaim – In case of a planned hospitalization, you can submit a pre-authorization form along with the medical card in advance. For an emergency medical treatment, you can present the insurance company's medical card to receive cashless hospitalization at any network hospital and then complete the pre-authorization form within the time limit.

Reimbursement – If you are unable to make a cashless claim, you can opt to get a reimbursement for your expenses. To file for a reimbursement mediclaim, you must submit the bills, prescriptions, and medical reports along with a complete claim form with the insurance company.  

Q: What do I need to do after I get hospitalized?

If you are admitted to a hospital that is a part of your insurer’s hospital network, you will be required to file a claim form and present your insurance card to receive cashless hospitalization benefits. However, if the facility is not a part of the hospital network, you can claim reimbursement for your expenses.

Q: What is a cashless mediclaim policy?

When receiving treatment at a hospital, the policyholder does not have to pay upfront due to the cashless aspect of the health insurance coverage. In this instance, the bills are settled between the insurance company and the hospital, with no cash payment required from the policyholder.

Q: What is a group mediclaim policy?

A group mediclaim policy covers a specific group of people, usually members of a professional association, society, or employees of an organization. The health and medical expenses will be covered by the group medical insurance coverage.

Q: What is overseas mediclaim policy?

An overseas mediclaim policy is a type of insurance that protects you against the costs of hospitalization in a foreign nation. While the insured is outside of India, this coverage covers medical expenses. It covers both inpatient and outpatient medical bills.

Q: What is the age criterion to buy a mediclaim policy?

A mediclaim policy's minimum entry age is usually 18 years, and the exit age is 65 years. Some insurance companies, however, do provide coverage plans for children as young as five years old.

Q: When can you file a claim after buying a mediclaim policy?

Most mediclaim plans have a waiting period of 30 days. You can file for claims after this period ends. However, in case of a pre-existing condition, the waiting period may be longer.

Q: Which mediclaim policy covers dental treatment?

Most mediclaim policies do not cover dental treatments, but you can buy a dental health insurance separate from your medical insurance.

Q: Which mediclaim policy covers LASIK surgery?

There are some mediclaim plans that do include coverage for LASIK eye surgery. Hence, before signing up, it is important to go through your premium and coverage plan and ensure that the policy covers everything you need.

ARN No: PCP/MCP/111022

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