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Health Insurance / Mediclaim

Health insurance is a type of insurance coverage that pays for medical and surgical expenses incurred by the insured. Health insurance can reimburse the insured for expenses incurred from illness or injury, or pay the care provider directly. now
One development that can cause a serious setback to a family’s finances is the occurrence of a major or prolonged disease, or the requirement of a major surgical procedure. Increasing privatisation of healthcare has made healthcare more expensive. Advancements in medical technology mean that you can live longer, but high-end procedures also come with a huge price tag. The answer to the high and rising cost of healthcare (the rate of healthcare inflation in the country is about one-and-a-half to twice consumer inflation) lies in purchasing adequate health insurance for your family.
Health Insurance Coverage.
Hospitalization cost, operation theatre charges.
Surgeon/ medical practitioner fees and nursing expenses.
Medical tests expenses, drugs bills, chemotherapy, radiotherapy, and etc.

Types of Health Insurance

Hospitalisation plans: These are indemnity covers: they compensate you for the cost incurred on hospitalisation (you must be hospitalised for at least 24 hours). The maximum they pay out is determined by the sum assured of the policy. These are the most popular type of health insurance covers in the country.  Hospitalisation covers are of two types. In individual policies, the sum insured can only be utilised by the individual in whose name the policy has been issued. Family floater policies cover the entire family. The sum insured can be shared by the entire family during a year.  Basic hospitalisation covers only cover the cost of treatment when a person is hospitalised. But many companies now offer policies that have expanded the ambit of coverage to include cost of maternity, day care procedures, pre- and post-hospitalisation care, at-home care, and so on.
Top-up policies: These are meant to enhance your level of coverage. They reimburse you when your healthcare costs rise above a certain limit called the deductible. You need to pay out of your own pocket, or your base policy should cover you up to that limit. Once your costs cross that level, the top-up policy provides compensation.  Usually top-up policies are bought by people whose base policy, either self-purchased or employer-provided, has a small sum assured. People also buy them to keep pace with the rising cost of healthcare. These policies are cheaper than a basic mediclaim policy (due to the deductible clause).
Hospital daily cash benefit: Besides the cost of treatment, hospitalisation and illness entail many other costs. Cash benefit plans are meant to cover those expenses. They also provide a substitute for the loss of income during illness. These policies pay a pre-defined sum of money for each day of hospitalisation, and for a defined number of hospital days each year.
Critical illness plans: Some illnesses have a low incidence but can cause massive damage to a family’s finances because of the high cost of treatment. Critical illness plans pay out the sum assured to the beneficiary as soon as he is diagnosed as suffering from one of those diseases. Some of the diseases covered by these policies include heart attack, cancer, etc. The list of diseases covered varies from policy to policy. Treat them as a supplement, and not as a substitute, for basic mediclaim policies.
Documents Required Some of the documents required at the time of buying a mediclaim policy include identity proof, age proof, and address proof.
However, a wide range of documents need to be submitted to the TPA (third-party administrator) to claim reimbursement. These are as follows:

  • Hospital discharge card.
  • In-patient hospital bills signed by the insured.
  • Investigation reports and their bills.
  • Prescription of doctor and chemist’s bills.
  • Claim form signed by the insured.
  • Detailed break up of consumables and disposables used for medical and surgical procedure.
  • Copy of the TPA ID card or current policy copy and previous year's policy copies (if any).
  • Any other document asked for by the TPA.

Exclusions Exclusions refer to diseases or conditions that are not covered by your health insurance policy. Before purchasing a health cover, read the fine print of the document to understand which diseases and conditions are not covered. While comparing policies, go for one whose list of exclusions is smaller. Often, people complain about having been cheated by the insurer when the latter doesn’t reimburse them for a particular treatment. But the fault could lie with them: they may not have read the fineprint of their policy document to understand the list of exclusions.
Exclusions may be divided into the following categories:
Permanent exclusions: These are conditions that are never covered by a health insurance policy. These include treatment of mental illness, sexually-transmitted diseases, AIDS, abortion, cosmetic surgery, self-inflicted injuries, and so on. The list of permanent exclusions varies from one policy to another.
Exclusions with waiting period: In case of many illnesses, the waiting period lasts for only a specified period and not forever. It usually ranges from 2 to 3 years. Some of the conditions for which health insurers impose a waiting period include cataract, hysterectomy, hernia, fistula, joint replacement, etc. Typically these are conditions for which treatment is not urgent. The waiting period is imposed to ensure that people don’t buy a health cover after they have contracted these conditions. When comparing policies, buy one that has a shorter waiting period.
Pre-existing illnesses: These refer to illnesses which a person already has at the time of buying the policy. Companies usually cover pre-existing illnesses after 2 to 4 years. Experts suggest that you buy a health cover as early as possible when you have fewer diseases and conditions. That way any ailment that arises after the policy has been in force for a few years will be covered, and the insurer will have no ground to reject your claim. In case of senior citizens, pre-existing illnesses may not be covered for the rest of the life. This makes it essential that you buy health insurance for your parents before they turn 60. Nowadays, however, many companies offer health insurance for senior citizens with a limited waiting period for pre-existing diseases. Such policies often come with a high co-payment clause, requiring you to pay a part of the cost of treatment out of your own pocket.

What is Mediclaim?

Mediclaim is an insurance product that reimburses the expenses you incur in the event of hospitalization or domiciliary care. It can either reimburse your expenses when you submit relevant bills, or enable you to have an entirely cashless hospitalization where your insurer will directly deal with the hospital – letting you focus on treatment and healing.

  • Premiums – that are payable on Mediclaim policies differ between insurers but are based on certain criteria like age of the proposer, geographical area of treatment, sum insured, term of plan, etc.
  • Age – of insured persons can range from 5 years to 80 years, although age criteria and range insurable varies between companies.
  • Family cover – You can provide Mediclaim cover for your entire family with the payment of one master premium. This may also make you eligible for discounts on your premium, depending on your provider.
  • Overseas Mediclaim Policies – A large number of insurance companies offer Mediclaim policies that cover you in India and overseas, subject to certain predetermined conditions.
  • Claims – are administered largely through Third Party Administrators (TPAs) these days, but a few insurers deal with claims in-house.
  • Types – Mediclaim policies are available in a range of types, depending on the need and the category of those to be insured. You can get individual policies, group policies, senior citizen policies, critical illness policies and special maternity policies.
  • Tax benefits – under Section 80D are available up to Rs.15,000 on mediclaim premiums for yourself, spouse and dependent children. An additional Rs.15,000 of tax exemption is available if you insure your parents, and the amount goes up to Rs.20,000 if they are senior citizens.
How is Mediclaim different from Health Insurance?

Insurance companies offer health insurance products under two broad categories – indemnity policies and benefit policies:

  • Benefit policies are mostly traditional health insurance policies which pay out a pre-determined “sum insured” amount on the occurrence of an accident, or diagnosis of any of the illnesses, diseases, conditions, etc. that have been insured against. Traditional insurance policies work this way, offering you a financial benefit up-front and not necessarily requiring you to submit hospital bills, etc.
  • Indemnity policies compensate or reimburse you for the expenses incurred during your hospitalization or domiciliary care, on the submission of necessary proofs, up to the limiting amount mentioned in the policy. Mediclaim is an example of such a product. Although with recent advancements, mediclaim enables cashless hospitalization facilities wherein the insurer pays the hospital directly.

The most important difference between mediclaim and health insurance is that mediclaim will only reimburse your expenditure, and not provide you with a large-sum financial benefit in case you are rendered unable to earn.

Types of Mediclaim policies in India:
  • Individual Mediclaim - where you basically insure yourself against the financial liabilities of hospitalization.
  • Family Floater - where you can provide additional coverage for your entire family, and be tension-free in matters of hospital bills and related expenses.
  • Group Mediclaim - where an employer or person in charge of a group of people wishes to add to their remuneration the benefits of cashless hospitalization and / or reimbursement on hospitalization expenses.
  • Overseas Mediclaim - where all your hospitalization and related expenses are taken care of during your stay (or travel) outside India.
  • Low-cost Mediclaim - is for the underprivileged masses. Employers of small-scale and medium-scale industries insure their employees and their dependants for as low as Rs. 1,600 per annum.
  • Senior Citizen Mediclaim - while this type of mediclaim requires testing and/or special provisions, it’s a huge step forward for the industry as they can safely insure senior citizens at competitive premium rates.
  • Critical Illness Mediclaim - among the most expensive treatments in the field today are those incurred on treatment of critical illnesses. Critical Illness Mediclaim policies usually offer a higher claimable amount, and include some of (but are not strictly limited to) the following:
What does a Best Mediclaim policy cover?

Mediclaim policies offer excellent benefits and coverage for a wide range of expenses, depending on your insurance provider. Mediclaim policies in general offer the following benefits and cover:

  • Hospital charges – all direct charges that you incur as a result of hospitalization like OT charges, medicines, blood, oxygen, diagnostic material, x-rays, chemotherapy, radiotherapy, pacemakers, donor expenses during organ transplants, etc.
  • Day-care treatment – expenses towards specified technologically-advanced treatments where 24-hour hospitalization is not needed.
  • Pre and post-hospitalization expenses – for a period of 30 days before and up to 60 days after hospitalization and may include assistance in availing emergency services like ambulance, etc.
  • Hospital accommodation charges – in regular wards or in ICUs are fully reimbursed, or taken care of with the cashless hospitalization facility.
  • Medical professional’s fees – like doctor’s fees, nurse’s fees, anaesthetist's charges, etc.
  • Investigation charges.
What does Mediclaim Policies not Cover?

Different providers have different exclusions in their policies, some may not even consider the standard exclusions and provide benefits anyway. Nevertheless, a standard Mediclaim policy would not cover you for treatment or expenses arising from or attributable to the following:

  • All pre-existing diseases, medical conditions and injuries that are present before the policy comes into force.
  • All diseases and medical conditions (unless otherwise specified in your policy document) that arise within the first 30 days of your policy commencement date.
  • Injuries or medical conditions caused by war (whether it be declared or not), hostile foreign invasion or attack, war-like operations, etc.
  • Plastic surgery and circumcision (which is not necessary as treatment for illness or accident), cosmetic or aesthetic treatments of any kind.
  • Cost of spectacles, hearing aids, contact lenses, etc.
  • Dental treatment and surgery whether it is corrective, cosmetic or aesthetic – unless it arises due to an accident and requires hospitalization.
  • Intentional self-injury and attempted suicide.
  • Alcohol / drug abuse.
  • STDs like HIV / AIDS, human T cell lymphotropic virus type III (HTLB III), lymphadenopathy associated virus (LAV) or their variations.
  • X-rays, laboratory tests and other expenses incurred not in direct relation to the treatment.
  • Injury or disease arising from nuclear radiation or exposure to nuclear weapons and materials.
  • Pregnancy, childbirth, miscarriage, abortions, caesarean section, etc. or any complication arising from these.
  • Nautropathy related treatments.
How do I claim the benefits of my Mediclaim policy?

Reimbursement - It is important to keep the insurer or the TPA informed of your hospitalization as and when it happens. This is important because insurers and TPAs have a very strict definition of the term “hospital” and will not honour claims for treatment received in medical facilities that fall outside their definitions. It’s important to know which hospitals are in their list, before being admitted.
Upon hospitalization, you must keep a careful tally of all expenditures and maintain records of all bills that you have been given. Don’t take a high-end room and lavish hospital facilities if you can’t afford it without insurance (as insurers will scrutinize these claims and judge whether that extra-comfortable hospital bed was a vital requirement for your recovery). Avoid listing personal comfort items as they will most likely not be honoured.

Cashless claims Cashless Planned Hospitalization - If you have time to plan your admission to the hospital, you need to send your preauthorization at least 72 hours before your actual hospitalization. This results in a smooth, cashless mediclaim experience.

Cashless Emergency Hospitalization - In an emergency like a car accident, there won’t be time to send a preauthorization, etc. In such a situation, you need simply produce your Medi Assist ID Card at the network hospital. This will facilitate cashless hospitalization and get you four hours in which you must send your preauthorization request. As we can see here, it’s important to carry your Medi Assist ID Card with you at all times.

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