Medical emergencies come unannounced and if you haven’t got a health coverage, be ready for a massive medical bill due to hospitalisation. Despite the rising costs of healthcare, several of us ignore and do not cover our family and ourselves with a Mediclaim policy. But, what is Mediclaim Policy? Let’s understand its features, benefits and coverage.

Mediclaim Policy: Features, Benefits and Coverage - Acko

What is a Mediclaim Policy?

Mediclaim policy is an insurance cover which shields you against increasing medical costs arising out of hospitalisation. It offers financial protection in case of hospitalisation due to illness or an accident. Similar to other forms of insurance, Mediclaim policy benefits can be exercised by paying a premium annually. This type of insurance policy comes with a defined policy period and needs to be renewed to continue enjoying the benefits of the policy.

Mediclaim is a form of health insurance through which you can either be reimbursed for expenses arising out of hospitalisation or you can choose the cashless process to cover your hospitalisation expenses. Additionally, the premium that you pay is eligible for tax exemption under Section 80D of the Income Tax Act 1961, making it a good investment.

Features and Benefits of Mediclaim Policy:

So, how does a Mediclaim policy benefit you? Let’s look at some of the features and benefits of the policy:

  • It offers the ease of cashless hospitalisation.
  • You can opt for self or for the entire family.
  • It shields you from the financial burden.
  • Removes expenses paid from your pocket.
  • Insurance companies will handle the expenses arising out of hospitalisation.
  • Ease of buying through online health insurance companies.
  • It offers tax exemptions.
  • Avail cost-effective healthcare services.

Types of Mediclaim Policies:

There are different types of Mediclaim policies to cater to various needs and requirements. Let’s look at these in detail:

  • Individual Mediclaim Policy: Under this type of policy, only the policyholder is covered against major medical expenses arising out of hospitalisation.
  • Family Floater Policy: The policyholder and other family members such as parents, spouse, and children are covered under this plan.
  • Group Mediclaim Policy: An employer purchases medical policy for the employees or members of the organisation under this plan.
  • Senior Citizen Mediclaim Policy: Under this type of plan, senior citizens are covered for medical expenses with special provisions.
  • Critical Illness Mediclaim Policy: Medical expenses arising out of critical illnesses are high and the Critical Illness Mediclaim policy offers to cover illnesses such as cancer, kidney failure, cardiovascular-related illnesses, etc. 
  • Overseas Mediclaim Policy: Under this type, it allows you to raise claims from hospitalisation expenses that were incurred overseas.
  • Low-Cost Mediclaim Policy: For those looking for a lower sum insured, you can this type of policy. Also, such policies cater to the underprivileged section of the society. Usually bought by small and medium scale industries employers to cover their employees at low-priced premiums.

What Does a Mediclaim Policy Cover?

An excellent Mediclaim policy covers you against a wide range of medical expenses and it can vary between policies. Here are some of the most common inclusions of a Mediclaim policy:

  • Hospitalisation Costs: It includes all medical expenses incurred during the hospitalisation of the policyholder or the beneficiaries of the policy. It covers expenses related to diagnostic procedures, OT charges, medicines, blood, x-ray, oxygen, etc.
  • Pre and Post-Hospitalisation Expenses: Medical expenses arising before 30 days of hospitalisation and up to 60 days post-discharge are covered under the Mediclaim policy. However, you need to check with the insurer if this type of hospitalisation is part of the policy.
  • Day-Care Expenses: Medical expenses arising out of advanced medical treatments which do not require the patient to be hospitalised for more than 24 hours is covered.
  • Hospital Room Expenses: Costs towards regular wards or Intensive Care Unit (ICU) are fully reimbursed or through the cashless facility.
  • Doctor’s or Medical Professionals’ Fee: Doctor’s consultation fee or medical professionals’ charges such as nurses’ fee, etc. are covered.

Check: 10 Things to Consider Before Buying Health Insurance

What is Not Covered in Mediclaim Policy?

Every Mediclaim policy has some exclusions and varies from one insurance company to another. Here are some of the common exclusions in Mediclaim policies:

  • Pre-existing illnesses.
  • Dental treatments.
  • Sexually transmitted diseases.
  • Birth control and hormonal treatments.
  • Vaccinations.
  • Plastic surgery.
  • Cosmetic surgery and obesity-related treatments.
  • Maternity expenses if not opted as an Add-on feature.
  • Non-medical expenses such as service charges, administrative charges, toiletries, etc.
  • Ailments and diseases contracted within a set period from the policy purchase date.

How is Mediclaim Premium Calculated?

Insurance companies calculate the Mediclaim policy premium based on factors such as age, geographical location, the sum insured, pre-existing medical condition (if any), the extent of the coverage, number of members to be insured, etc. However, the final premium will be decided by the insurer based on your unique needs and financial needs, which is as per the IRDAI guidelines.

Things to Remember When Buying a Mediclaim Policy:

If you’re planning to buy a Mediclaim insurance policy, here are the factors that you need to consider:

  • Sum Insured (Coverage): While choosing the best Mediclaim policy, you need to select an adequate sum insured or the coverage amount. You might pay a higher premium for a higher sum assured, but it’s imperative that you choose a policy based on your needs.
  • Individual or Family Floater: Before you finalise your Mediclaim insurance, you need to check if this policy is for an individual or is it for your entire family. However, in a family floater type Mediclaim policy, the entire sum insured will be jointly held by the members of your family who are beneficiaries of the policy amount.
  • Co-Payment: Under this clause, you as a policyholder, are expected to pay a specific percentage of the claims and the insurer bears the rest of the medical expenses.
  • Network Hospitals: Choose an insurance provider with a wide range of network hospitals as the cashless facility is available only with these hospitals. This will help you choose from several options.
  • Waiting Period: While registering a claim, insurance companies have a waiting period before which you cannot claim for any medical expenses. Also, insurance companies have a waiting period for pre-existing diseases or illnesses. Check for these exclusions to make the best decision to buy a Mediclaim policy.
  • Add-ons: Usually, insurance companies do not offer Add-ons on Mediclaim policy; however, if they do, you can buy these extra features and enhance your insurance cover. Please do note that Add-ons will increase your insurance premium.

Frequently Asked Questions:

Here are some of the most frequently asked questions about Mediclaim policy:

How to choose the best Mediclaim policy?

Before buying a Mediclaim policy, finalise if the policy is for an individual or a family floater plan. Also, check for the renewability age and if the policy covers pre-existing diseases. You can also check some of the online health insurance companies about the features and benefits and select the right policy.

Why choose a Mediclaim policy?

With medical expenses on the rise, a Mediclaim policy will cover you in case of hospitalisation as well as domiciliary care during the tenure of the policy. With a Mediclaim policy, you don’t have to pay from your pocket in case of unexpected hospitalisation.

What is cashless Mediclaim policy?

Medical expenses arising out of your or your family’s hospitalisation will be paid directly by the insurance company to the hospital where you have availed the treatment. Cashless Mediclaim policy can be availed only with the insurer’s network hospitals.

What is group Mediclaim policy?

It covers all insured employees of a company or organisation in the case of hospitalisation or domiciliary care during the policy period.

How to renew a Mediclaim policy?

New-age insurance companies have gone online. You can visit their website to pay the renewal amount for the Mediclaim policy. Or, you can visit the respective insurance company’s branch to renew the Mediclaim policy.

Is Domiciliary hospitalisation covered under the Mediclaim policy?

For a domiciliary hospitalisation, one must fulfil certain conditions. This includes medical treatment should more than 3 days and the condition of the patient is such that he/she cannot move to a hospital for treatment or if accommodation is not available in a hospital. Additionally, there are some exclusions under the domiciliary hospitalisation. Read the policy wordings to understand illnesses that are not covered.

What is a floater Mediclaim policy?

Under this type of Mediclaim policy, all members of your family who have been included in the policy share the sum insured. Family members include self, parents, spouse, and children.

What is an overseas Mediclaim policy?

This type of Mediclaim policy covers you in case of an accident or illness when travelling overseas.

Does a Mediclaim policy cover dental treatment?

Not every Mediclaim policy covers dental treatment. However, you need to check with the insurance provider if they have a Mediclaim policy which includes dental as well.

How does a Mediclaim policy work?

Mediclaim policies offer financial cover in case of hospitalisation due to an accident or sudden illness. Hence, you don’t have to pay from your pocket for medical expenses which require hospitalisation for more than 24 hours. You can either opt for a cashless hospitalisation through a network hospital or you could pay and then submit for reimbursement.


News Realted to Mediclaim Policy:

Existing Mediclaim and Arogya Sanjeevani Insurance Policy to Cover COVID-19 Hospitalisation

– April 6, 2020

In a press release, the apex body of insurance companies IRDA (Insurance Regulatory and Development Authority of India) has announced that the Arogya Sanjeevani insurance policy will now cover hospitalization expenses for the treatment of COVID-19. The government has launched the Arogya Sanjeevani back in January this year to offer basic health insurance between Rs.1 lakh and Rs.5 lakh. The IRDA has also said that insurers are free to charge the premium for the product. The apex body also said that all mediclaim policies which are currently in force will cover the treatment cost of hospitalization due to coronavirus infection.



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