Things to Know about Mediclaim Policy

A Mediclaim policy is a popular type of health insurance that covers only the medical expenditures one incurs while hospitalized. The coverage amount extended under this policy is limited up to the sum insured. At a time when the cost of accessing medical treatment is rising uncontrollably, a mediclaim policy serves as a reliable ally. It should be such an insurance plan is made available based on individual and floater sum insured.

Read along to know more about the merits of a mediclaim policy.

Things that are Covered Under Mediclaim Policy

Here’s a list of expenses that are covered by an extensive mediclaim policy:

  • Hospitalization Charges

It covers all direct hospitalization-related expenditures, such as OT, diagnostic tests,  medicines, chemotherapy, blood, oxygen, x-ray, donor expenses, pacemakers, etc.  Mediclaims also cover unintentional hospitalisation and illness.

  • Room Charges

Mediclaim policies extend the benefits of cashless hospitalization at their network hospitals. This accounts for the charges of the critical care unit and regular ward, which are either covered by an insurance provider or reimbursed by them.

  • Medical Professional Fees

The fees charged by medical professionals such as doctors, nurses, surgeons, anesthetists, etc., during hospitalisation are reimbursed by the mediclaim provider.

Besides these, individuals must make it a point to find out the expenses and conditions that are not covered by the mediclaim policy. This will help them prepare better for such circumstances and account for the same without waiting around only to get their claim rejected.

What Aspects are Not Covered in a Mediclaim Policy?

Every mediclaim policy is bound by some limitations, which are publicly disclosed on policy terms and websites. However, it is the responsibility of the intending policy buyer to be more attentive toward such exclusions.

Here’s a list of standard exclusions that are not covered by a mediclaim plan:

  • A mediclaim insurance policy will not account for the insured’s pre-existing ailments until the pre-defined waiting period concludes.
  • Critical illnesses and/or medical conditions diagnosed within 30 of purchasing the policy are usually not covered under a mediclaim policy.
  • Certain ailments such as any joint replacement surgery, gall bladder operation, etc., are not accounted for by the mediclaim policy for at least 2-4 years (according to policy term)
  • The expenses incurred on insured’s dental surgeries unless it needs them to be hospitalized
  • Any hormonal or birth control treatment
  • Medical complications faced during childbirth and ectopic pregnancies
  • Congenital anomaly
  • Suicide attempt
  • Addiction to drugs and alcohol

Note that the mediclaim insurance providers may have a distinct set of exclusions that may differ from other insurance companies. Hence, it is recommended to check the same in detail before deciding to opt for a certain insurance provider.

Mediclaim Policy Claim Procedure

Individuals can raise two types of claims under their mediclaim policy, namely – reimbursement claim and cashless claim.

Reimbursement Claim Procedure

For reimbursement claims, you must notify the insurance provider that hospitalisation has occurred or is imminent. Individuals can notify the same by simply writing an email or getting in touch with the insurance provider’s customer service representative. It is vital to collect all medical documentation from the hospital post-treatment.

Subsequently, to receive a refund under the mediclaim, the insured must send all hospital bills and related payment receipts, including prescription costs, original discharge card, and mediclaim form to the insurance provider. Once the claim is verified and approved, the insurance company will refund the money.

Cashless Claim Procedure

Cashless claims allow a patient to receive urgent treatment in a network hospital free of cost. In such a case, the insurance provider settles the bill directly with the network hospital. In other words, the insured does not have to pay any money to the hospital to seek treatment. However, to avail of the benefit of cashless treatment, the insured must get treated at the insurance provider-approved or network hospital.

Here’s how one can raise a cashless claim:

Step 1: Collect a pre-authorization form from the insurance desk at the hospital

Step 2: Fill out the form with the required information

Step 3: Get the duly filled form stamped by the hospital

Step 4: The form will be submitted for Third Party Administrator (TPA) or the insurance company’s approval

Step 5: Following its review, the insurance provider will authorise the treatment and convey to the hospital that the treatment of the insured will be covered by them.

Step 6: Post-discharge, sign all the documents and receipts

Once these steps are completed the insurance company will release the payment to the hospital.

Mediclaim Policy vs. Health Insurance

The key differences between mediclaim policies and health insurance plans are detailed below:

Meaning: A mediclaim policy is a type of insurance that reimburses medical expenses incurred by the insured only during hospitalization. On the other hand, health insurance covers all medical expenses, along with pre and post-hospitalisation charges. It also pays the insured a lump sum amount following the diagnosis of a critical illness covered by the policy, regardless of the medical expense.

Scope of Coverage: Mediclaim policy offers narrow coverage since it only accounts for hospitalisation charges arising from illness or accident. Alternatively, health insurance is known for its wider coverage that includes hospitalisation expenses, critical illness, ambulance charges, etc.

Premium: When compared to health insurance, the premium of mediclaim is relatively low because of its limited coverage.

Add-ons: Mediclaim policies do not offer the feature to include add-on covers to the main policy. On the other hand, individuals can include multiple add-ons such as critical illness coverage, maternity benefits, etc., to their existing health policy.

Documents Required For Purchasing a Mediclaim Policy

When purchasing medical insurance coverage, the following documents are deemed essential:

  • Proposal form
  • Age proof like – an Aadhaar card, voter ID card, passport, driving license, etc.
  • Identity-proof such as – an Aadhaar card, passport, driving license, and other government ID
  • Medical records, test reports, etc.

Your choice of insurance provider may ask you to provide additional documents based on their rules or insurance policy. Make sure to check all the requirements beforehand to eliminate the chance of delay when getting a new mediclaim policy.

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