Mediclaim Policy

A Mediclaim policy is a type of health insurance plan that offers financial coverage for medical expenses incurred due to illness, injury, or hospitalization. Unlike standard health insurance, Mediclaim policies typically cover hospitalization expenses such as room rent, doctor’s fees, diagnostic tests, and pre-and post-hospitalization costs. These policies provide a safety net for individuals and families, ensuring that unforeseen medical emergencies do not strain personal finances. By paying a regular premium, policyholders can avail of cashless hospitalization or get reimbursed for medical bills.

Several variants of mediclaim policies are currently available in India including the following:

• Individual Mediclaim Policy: Provides coverage to an individual against hospitalization expenses. It’s ideal for people who prioritize personal health coverage.

• Family Floater Mediclaim Policy: Covers an entire family under a single sum insured. If one family member makes a claim, the total sum insured reduces accordingly.

• Senior Citizen Mediclaim Policy: Designed for elderly individuals above 60 years. It covers age-specific health issues with a higher premium.

• Critical Illness Mediclaim Policy: Provides lump sum benefits if the policyholder is diagnosed with critical illnesses like cancer, heart attack, or stroke.

• Group Mediclaim Policy: Offered by employers to employees as part of employee benefits. It’s a cost-effective solution for organizations.

• Overseas Mediclaim Policy: With this plan, you can benefit from financial coverage for medical treatments received outside India, ensuring global healthcare protection and peace of mind during international travel.

• Sum Insured: Choose a policy with a sufficient sum insured to cover hospitalization costs for your family’s needs.

• Network Hospitals: Check if the policy’s network hospitals are near your location for easy access to cashless treatment.

• Pre and Post-Hospitalization Cover: Ensure the policy covers medical expenses incurred before and after hospitalization.

• Room Rent Limit: Policies may have caps on room rent; opt for one that’s suitable for your comfort.

• Cashless Facility: A cashless claim facility minimizes out-of-pocket expenses during emergencies.

• Renewability: Opt for lifetime renewability to ensure continuous coverage as you age.

• Waiting Period: Check the waiting period for pre-existing conditions and certain ailments.

• Hospitalization Expenses: Covers room rent, doctor’s fees, nurse’s fees, and treatment charges.

• Pre and Post-Hospitalization: Pays for medical expenses incurred before and after hospitalization.

• Daycare Procedures: Covers treatments that do not require a 24-hour hospital stay.

• ICU Charges: Includes costs of staying in an Intensive Care Unit (ICU).

• Diagnostic Tests: Expenses for required diagnostic tests are covered.

• Ambulance Charges: Reimburses or provides cashless cover for ambulance transportation.

• COVID-19 Treatment: Most policies now cover COVID-19 treatment under their hospitalization clause.

Here are common exclusions in most mediclaim policies:

• Maternity Expenses: Unless covered under an add-on.

• Pre-Existing Diseases (PEDs): A waiting period applies.

• Waiting Period for Specific Ailments: 30 days or more for general conditions.

• Vaccinations: Excluded unless medically required.

• Dental & Cosmetic Procedures: Unless caused by accidents.

• Birth Control & Hormonal Treatments.

• STDs & HIV/AIDS: Excluded unless specified.

• Self-Inflicted Injuries.

• Non-Medical Costs: Administrative and service charges.

• Initial Policy Period: Ailments diagnosed within the first 30 days.

Coverfox offers a fast, simple, and transparent process to compare, select, and purchase Mediclaim policies online. Users can access personalized recommendations, expert advice, and exclusive discounts. With a user-friendly platform, Coverfox provides policy comparisons, real-time premium quotes, and seamless claim support.

• Assess Your Needs: Consider family size, health history, and medical needs.

• Compare Plans: Use Coverfox’s comparison tool to choose the best plan.

• Check Policy Exclusions: Look for waiting periods, room rent caps, and disease-specific exclusions.

• Look for Add-ons: Opt for add-ons like critical illness cover and maternity cover.

Purchasing a Mediclaim policy via Coverfox offers tax benefits under Section 80D of the Income Tax Act. Policyholders can claim deductions of up to ₹25,000 for individuals and up to ₹50,000 for senior citizens. Coverfox’s seamless platform ensures easy policy purchase, helping users maximize tax savings.

Some of the most essential documents that are required to purchase any mediclaim policy include the following:

• A duly filled-in and signed proposal form
• A valid age proof like an Aadhaar card, passport, voter’s ID or passport
• A photo identity proof like a passport, DL, or Aadhaar card
• Authentic address proof like a passport, DL, Aadhaar card, any utility bill, ration card, or voter’s ID
• A recent passport-size photograph
• Medical test reports if necessary before plan purchase.

Mediclaim policies offer two types of claim settlements:

• Cashless Claims (for planned and emergency hospitalization)

• Reimbursement Claims (for non-network hospitals)

1. Cashless Claims

a) Cashless Claims for Planned Hospitalization

A cashless claim ensures that your insurer directly pays the medical bills to the hospital.

Steps to Follow:

• Get Admitted: Choose a hospital from your insurer’s network hospital list.

• Inform Your Insurer: Notify your insurer and visit the TPA (Third-Party Administrator) desk at the hospital.

Pre-Authorization Form:

• Collect the form from the TPA desk.
• Get it signed by the attending doctor.

• Submit it to the TPA for approval.

• Approval: The insurer/TPA evaluates and approves the claim amount based on medical necessity.

• Treatment Continues: The hospital proceeds with treatment while coordinating with the insurer.

• Non-Covered Expenses: Pay for expenses not covered under your Mediclaim policy, such as exclusions and non-medical charges.

b) Cashless Claims for Emergency Hospitalization

In emergencies, you can still avail of the cashless facility for quick admission and treatment.

Steps to Follow:

• Immediate Admission: Visit the nearest network hospital and inform the hospital’s TPA desk.
• Submit Pre-Authorization Form: Complete and submit the form within 4 hours of hospitalization.
• Approval: The TPA reviews the claim based on the emergency condition and plan coverage.
• Treatment Continues: Your treatment proceeds while the hospital coordinates with the insurer to settle bills directly.

2. Reimbursement Claims

If you receive treatment at a non-network hospital, you can opt for reimbursement of medical expenses.

Steps to Follow:

Pay the Bills: Settle the medical expenses upfront with the hospital at the time of discharge.

Collect Documents:

Obtain all original bills, payment receipts, doctor’s prescriptions, and discharge summaries.

• Submit the Claim: File the claim along with all required documents to the insurer/TPA within the specified timeframe.

• Approval and Refund: The insurer verifies the submitted documents and reimburses the eligible expenses directly to your registered bank account.

Coverfox simplifies the Mediclaim policy purchase process by offering a digital-first approach. Users can compare policies from leading insurers, get instant premium quotes, and purchase policies online. Additionally, Coverfox provides 24/7 claim support and personalized recommendations to ensure users find the best Mediclaim policy for their needs.