Mediclaim Policy in India: Types, Coverages and Benefits

Onsurity Editorial
December 24, 2024
8 min read

Table of Contents

Have you ever heard of the term “mediclaim” and gotten it mixed with a health insurance policy? A mediclaim policy is slightly different from a health insurance policy, but the two are often used interchangeably.

However, in this blog, we will elaborate on what a mediclaim policy is, what are the latest updates to it, and how it is different from health insurance and group health insurance. Also, we will explore its utility for employees who are already enrolled in a group health insurance plan. Read on to learn and make an informed decision about your health insurance needs.

What is A Mediclaim Policy?

Just like health insurance, a mediclaim policy also provides financial coverage for medical expenses incurred from treatment of certain illnesses, accidents, or due to hospitalisation.

Mediclaim aims to reduce the financial burden of an individual incurred from medical emergencies. With the help of a mediclaim cover, you can get cashless treatment at network hospitals or get a reimbursement for your hospitalisation (including pre and post-hospitalisation) expenses later.

Types of Mediclaim Policy

Mediclaim has two broad categorisations for providing healthcare cover to policyholders, these are individual policies and family floater health insurance plans.

1. Individual Mediclaim Policy

As the name suggests, the individual mediclaim policy provides medical coverage to an individual policyholder on a monthly, quarterly, half-yearly, or annual basis. The coverage under this policy includes expenses related to hospitalisation, pre-hospitalisation, post-hospitalisation, room rent, and ambulance charges.

This type of insurance is best suited for individuals who have no dependents or live alone.

2. Family Floater Mediclaim Policy

A family floater mediclaim policy provides medical cover to multiple family members under a single umbrella policy. All the family members covered under this type of insurance get a single cover, which means the sum insured can be utilised by any member in whole or by different members in parts.

It is best to get a family floater mediclaim for families if a member tends to have unused coverage in their individual mediclaim policy. A great advantage of getting a family floater mediclaim policy is that the premium costs less compared to that of an individual policy as the sum insured can be utilised by multiple members up to the limit.

Also read: 5 Best Group Medical Insurance for Family

Key Features of A Mediclaim Policy

1. Coverage

Under the mediclaim policy the costs such as – room limit, doctor’s consultation fee, and medical tests for hospitalisation exceeding 24 hours are included. Additionally, expenses incurred 30 days before hospitalisation and 60-90 days after hospitalisation are also included.

2. Cashless Hospitalisation

The mediclaim policy also allows individuals to get cashless treatment from network hospitals. In this scenario, the insurer settles the medical expenses directly with the hospital. In case, an individual does not get the treatment from a network hospital then the policy also allows for reimbursement of said medical expenses.

3. Daycare Treatment

Incidentally, treatments like cataract surgery or chemotherapy that do not require hospitalisation beyond 24 hours can also be claimed under the mediclaim policy.

4. Tax Benefits

Similar to health insurance, mediclaim also provides the policyholder with tax exemption benefits for premium costs, under section 80D of the Income Tax Act.

5. Family Coverage

A separate family floater mediclaim policy is available for including immediate family members under one comprehensive policy.

Suggested read: Top 10 Health Insurance Plans for Family

Exclusions of A Mediclaim Policy

1. Pre-existing Diseases

In case of pre-existing conditions, the policyholder can utilise mediclaim benefits only after a certain waiting period. This waiting period typically ranges from 2 to 4 years depending on the insurer.

2. Waiting Period

Various illnesses and procedures like – cataract surgery or joint replacement surgery have specific waiting periods before which the coverage can not be utilised for these procedures.

3. Cosmetic Treatment

Surgeries or procedures for cosmetic or dental purposes are not included in the mediclaim policy unless the need for it emerges due to injury or accident.

4. Maternity and IVF Treatment

Most mediclaim policies do not explicitly cover maternity expenses. So, any expenses related to pregnancy, childbirth, and fertility treatments (for example – IVF) are not included in the mediclaim policy.

5. Self-inflicted Injuries

Injuries suffered from self-harm, substance abuse, or suicide attempts are not included under the mediclaim policy.

6. Outpatient Treatment

OPD consultations, preventive health tests, and elective medical procedures are generally not covered under the mediclaim policy unless a separate provision has been created for it by the insurer.

7. Participation in Hazardous Activities

Injuries from high-risk activities like adventure sports or racing are excluded from the mediclaim policy unless an add-on is purchased by the policyholder.

Quick read: Employee Mediclaim Policy

Difference Between Mediclaim and Comprehensive Health Insurance

Mediclaim policies are primarily hospitalisation-focused with a defined coverage limit.
Health insurance policies can include broader benefits such as maternity coverage, OPD treatments, wellness programs, and critical illness coverage.

Mediclaim is ideal for those seeking affordable and straightforward health coverage for hospitalisation. For broader or more flexible benefits, consider a comprehensive health insurance plan.

Latest Modifications Introduced To The Mediclaim Policies

In 2024, significant updates were introduced to Mediclaim and health insurance policies in India by the Insurance Regulatory and Development Authority of India (IRDAI). Here are the key highlights:

1. Faster Claim Settlements

Cashless claim approvals must now be completed within one hour, and claims at discharge must be finalized within three hours. Delays beyond these timelines will result in insurers covering additional costs incurred by the policyholder.

2. Inclusivity in Coverage

There is no longer an upper age limit for purchasing health insurance, making policies more accessible to senior citizens. Insurers must also provide coverage for individuals with pre-existing or severe conditions like cancer or AIDS.

3. Reduced Waiting Periods

The waiting period for pre-existing conditions has been reduced from four years to three years. Specific treatments, like joint replacements, also follow this reduced timeline.

4. Simplified Renewal

Policies cannot be denied renewal due to past claims. Insurers are also prohibited from conducting fresh underwriting unless the policyholder requests an increase in coverage.

5. Customer-friendly Features

Insurers are now required to provide clear, concise policy documents with summaries of key terms. Additionally, they must set up dedicated support for senior citizens.

6. No-claim Bonus

Policyholders with no claims during the policy term can either receive a premium discount or an increased sum insured at renewal.

7. Enhanced Policy Portability

Transferring policies between insurers has been made smoother with stricter timelines for portability requests.

8. Alternative Medicine Coverage

Sub-limits for AYUSH treatments have been removed, allowing claims up to the full insured amount for alternative therapies like Ayurveda and Homeopathy. These updates aim to make health insurance more inclusive, transparent, and efficient for policyholders.

Also read: Mandatory Employee Insurance in India

Factors To Consider While Buying A Mediclaim Policy

There are several factors that you should consider before buying a mediclaim policy. Some of these factors are mentioned below.

1. Evaluate Your Requirements

While picking out the most comprehensive health cover, consider your medical history, family and health background, and potential health risks. This will help you determine the sum insured and coverage benefits.

2. Compare Different Policies

By comparing different policies based on premium costs, sum insured, and benefits, you can identify an insurance provider who offers you more benefits and coverage beyond the basic hospitalisation costs.

3. Network Hospitals For Cashless Treatment

An insurance provider that offers you the most extensive network of hospitals is typically the one you should go for. The network hospitals give you access to cashless treatment and prevent you from incurring out-of-pocket medical expenses.

4. No-claim Bonus

A no-claim bonus is a reward to the policyholder upon the non-usage of the insurance cover during the period of validity. The no-claim bonus can be either rewarded as a reduction in premium cost or as an increment to the sum insured.

Additionally, there are mediclaim policies that offer lifetime renewability, so that the policyholder can continue to enjoy policy benefits as they age. While opting for a mediclaim policy, ensure that the policy offers a no-claim bonus and lifetime renewability.

5. Check The Policy Terms

It’s always a good practice to read the policy documents. It contains essential information about the inclusions, exclusions, waiting period, and claim process. At the time of purchase, read the document carefully and clarify any doubts with your insurance provider to eliminate last-minute surprises.

Also Read: Difference Between Life Insurance and Health Insurance

Key Differences Between Mediclaim Policy and Group Health Insurance Policy

Both mediclaim and group health insurance policies help employees and their families get protection against medical expenses incurred from hospitalisation, accidents, and certain kinds of illnesses.

However, in group health insurance, employees get medical coverage without paying the premium. Here are some key differences between mediclaim and group health insurance that can help you make the most of your policy coverage:

Features	Mediclaim Policy	Group Health Insurance Policy
Coverage	Limited to hospitalisation, pre and post-hospitalisation expenses, and daycare procedures	Broader coverage, often including maternity, dental, and OPD (outpatient department) care
Cost To Employees	Premium is paid entirely by the policyholder	Premiums are paid by the employer. (Employee can pay a partial amount to add dependents or to get additional coverage)
Flexibility	Customisable based on personal needs (sum insured, riders, etc.)	Non-customisable, as the employer decides the terms of the policy
Pre-Existing Conditions	Covered only after a waiting period of 2-4 years	Immediate coverage for pre-existing conditions
Continuity	Policy continuity is available for as long as the premium is paid	Coverage ends when the employee leaves the organization or retires

A Mediclaim policy offers only hospitalisation-related coverage and is highly effective during medical emergencies. However, when it comes to medical expenses like – ambulance, preventive healthcare, maternity, wellness, etc. paying out of pocket is an expensive and strenuous affair.

Whereas, group health insurance is a more viable option when you’re looking for a policy that covers most of your healthcare expenses beyond hospitalisation. Additionally, since COVID-19, the government has made it mandatory for organisations with a team size of more than 7 people to get a group health insurance policy for their employees.

Quick read: Group vs Individual Health Insurance

About Onsurity

Onsurity is India’s leading health and wellness benefits provider that caters to business teams of all sizes. With the aim of democratising healthcare, Onsurity is making benefits like – Group health insurance and wellness services more accessible to businesses.

If your current employer doesn’t have you on a group health insurance plan then introduce them to Onsurity’s comprehensive health and wellness benefits. The healthcare membership offers insurance coverage, preventive healthcare, and wellness benefits, with the monthly subscription starting at just Rs. 145 per employee.

Get Started with Onsurity

FAQs:

1. Which is better - Mediclaim or health insurance?

A mediclaim policy offers basic health insurance coverage that focuses primarily on hospitalisation costs, such as – room rent, surgery, and medical expenses incurred during the inpatient treatment. However, health insurance is more comprehensive and covers not only the hospitalisation cost but also healthcare expenses like – maternity treatments, OPD treatments, critical illnesses, and wellness benefits.

2. Is there a waiting period for pre-existing diseases in the mediclaim policy?

Yes, there is a waiting period of 2-4 years for certain pre-existing diseases in the mediclaim policy. The exclusion of pre-existing conditions may vary from insurer to insurer.

3. What is the eligibility for getting a mediclaim policy?

The factors that can determine your eligibility for getting a mediclaim policy are – age, citizenship status, medical health checkups, pre-existing conditions, and identification documents.

4. What expenses are covered under a mediclaim policy?

Expenses related to hospitalisation, pre and post-hospitalisation expenses, and daycare procedures are generally covered under a mediclaim policy. There are certain inclusions like – pre-existing conditions, maternity benefits, and outpatient treatments that are subject to the insurer’s policy coverage.

5. What is the maximum sum insured in the mediclaim policy?

There is no maximum sum insured limit in the mediclaim policy. The policyholder can get coverage for as much as Rs. 1 crore under the mediclaim policy.

6. Is maternity covered under a mediclaim policy?

No, maternity benefits are generally not covered under a mediclaim policy. However, this inclusion can vary from insurer to insurer.

7. How can I renew my mediclaim policy?

Mediclaim policy can be renewed both online and offline. Here are the steps for renewing a mediclaim policy online: go to your insurance provider’s website’s renewal section; enter your policy number and registered mobile number; carefully review the policy details and renewal premium; and pay the renewal amount using any UPI, debit, or credit card.