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Mediclaim Policy

A health insurance plan that covers medical costs in the event of hospitalisation is known as a mediclaim policy. Having sufficient mediclaim insurance coverage guarantees that medical crises will not put a burden on your budget, especially in light of the escalating prices of healthcare. ...Read More

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Mediclaim Policy

What is a Mediclaim Policy?

Mediclaim Policy
April 11, 2025

Table of Content

 

A mediclaim policy is a type of health insurance that covers hospitalisation expenses arising from illness, injury, or surgery. This coverage offers a cashless option where costs are paid directly to the hospital, or it reimburses the insured for their medical fees.

In contrast to comprehensive health insurance, which offers greater coverage that includes preventative care and outpatient treatments, it only covers hospitalisation expenditures. Different Mediclaim policy options, including individual, family floater, and senior citizen policies, are available to meet different requirements.

Many mediclaim insurance plans also offer tax benefits under Section 80D of the Income Tax Act1. Additionally, integrating life insurance with a health plan ensures long-term financial security for dependents, covering not just medical expenses but also securing their future in case of an unforeseen event.

Benefits of Buying a Mediclaim Policy

Following are some of the benefits of purchasing the best mediclaim policy:

  • Financial Security

    • A mediclaim coverage makes sure that medical bills do not put a strain on people's or families' finances. Out-of-pocket costs may result from unexpected medical crises, and medical treatments, particularly in private hospitals, can be costly. Policyholders may protect their investments and obtain high-quality treatment by choosing the finest mediclaim coverage. This safety net contributes to stability in the event of unanticipated medical emergencies.

  • Cashless Treatment

    • Cashless hospitalisation is a feature of many mediclaim insurance plans that enables policyholders to obtain care at network hospitals without having to pay in advance. The burden of organising money in an emergency is lessened when the insurance company pays the hospital fees directly. This benefit makes sure that patients do not have to worry about money and can concentrate on getting better. It is especially useful for major treatments or surgeries where immediate cash availability might be a challenge.

  • Tax Benefits

    • Policyholders are eligible to claim tax deductions on their mediclaim coverage premiums under Section 80D of the Income Tax Act#. A yearly deduction of up to ₹25,000 is available to individuals, while up to ₹50,000 is available to senior persons. Additional discounts are available if you get mediclaim coverage for parents. In addition to offering cash assistance, this motivates people to spend money on health insurance for their families and themselves.

  • Coverage for Critical Illnesses

    • Critical illness coverage is available as an integrated element or as an add-on rider in certain mediclaim policy plans. These programs offer financial assistance for serious illnesses that need costly and drawn-out treatment, such as cancer, renal failure, or stroke. Furthermore, critical illness riders, in contrast to regular mediclaim insurance coverage, may pay out a flat amount upon diagnosis, guaranteeing financial support even if hospitalisation is not required.

  • Pre and Post-Hospitalisation

    • A mediclaim policy covers not only hospital bills but also medical expenses incurred before and after hospitalisation. This includes diagnostic tests, doctor consultations, and follow-up treatments that are essential for a full recovery. Typically, policies offer pre-hospitalisation coverage for 30-60 days and post-hospitalisation coverage for 60-90 days, ensuring that policyholders are financially supported throughout their treatment journey.

  • Ambulance Charges

    • Ambulance services may be expensive, yet medical crises frequently necessitate prompt hospital transfer. Depending on the plan, emergency road and air ambulance services are covered by mediclaim coverage. In situations like heart attacks, strokes, or accidents where prompt medical assistance is required, this guarantees prompt medical help without having to worry about transportation expenses.

  • Daycare Procedures

    • Advances in medical technology have made it unnecessary to stay in a hospital around the clock for many medical procedures, including minor operations, chemotherapy, dialysis, and cataract surgery. These nursery operations are covered by mediclaim policies, which guarantee policyholders financial assistance for treatments even if they do not need extended hospital stays. With this benefit, patients may get the treatment they need without having to pay more for hospital stays.

  • Preventive Health Checkups

    • Preventive health examinations are included in many mediclaim policy plans, allowing policyholders to identify any health problems early. Certain plans guarantee access to prompt testing for diseases including diabetes, high blood pressure, and cholesterol by providing yearly physicals at network hospitals. Better treatment results and long-term health advantages can result from early diagnosis. Additionally, this function promotes proactive health maintenance.

Types of Mediclaim Policies in India

Here are some of the main types of mediclaim policy available in India for you to choose from:

  • Individual Mediclaim Policy

    • A single person's medical costs are covered by an individual mediclaim policy. The policyholder pays premiums according to the sum insured, age, and health status. For persons looking for financial protection against hospitalisation costs resulting from illness, injury, or accidents, this plan is perfect, especially for young professionals and independent contractors.

  • Family Floater Mediclaim Policy

    • All members of the family are covered by a single premium and shared sum insured under a family floater mediclaim policy. It is an affordable choice that provides all family members with financial stability. Because it provides complete medical coverage for each member without requiring the purchase of numerous separate plans, the insurance is perfect for families with little children.

  • Group Mediclaim Policy

    • Employers provide their workers with a Group Mediclaim Policy as a reward at work. It covers pre-existing conditions, hospital stays, and occasionally maternity costs. These plans may be tailored by organisations according to the healthcare requirements of their employees and improve employee wellbeing by providing financial protection during medical emergencies.

  • Senior Citizen Mediclaim Policy

    • A Senior Citizen Mediclaim Policy is intended only for those sixty years of age and above. Hospitalisation, age-related ailments, and occasionally home-based medical care (domiciliary therapy) are covered. These plans assist older people in managing medical costs without using up all of their resources because they are more likely to experience health problems.

  • Cashless Mediclaim Policy

    • Policyholders who have a cashless Mediclaim coverage can get care at network hospitals without having to pay in advance. The insurer pays the hospital charge in whole, without deferring reimbursement. This removes the worry of finding the money for urgent medical care, which is quite helpful in emergencies.

  • Maternity Mediclaim Policy

    • Medical expenditures associated with pregnancy, such as prenatal and postoperative care, delivery fees, and baby expenses, are covered by a maternity mediclaim policy. Pregnancy problems are also covered by certain insurance. This plan ensures financial help during maternity-related hospitalisation and medical treatment, which is advantageous for expectant women and families preparing for childbirth.

Tax Benefits of a Mediclaim Policy

In addition to offering financial stability in times of medical emergency, mediclaim insurance offers substantial tax advantages under Section 80D of the Income Tax Act#. The premiums paid by policyholders for themselves, their dependent parents, and their families are deductible from taxes.

Individuals are eligible for tax benefits up to Rs. 25,000 under Section 80D of the Income Tax Act, 1961#, for the premiums paid towards the health insurance for self, spouse, and children. Additionally, they can claim up to ₹25,000 for premiums paid for their parents. which increases to ₹50,000 if the parents are senior citizens. However, in totality the maximum deduction available can be ₹1,00,000 if both self/family and parents are senior citizens.

These tax advantages incentivise individuals to purchase the finest Mediclaim coverage, guaranteeing savings on taxable income as well as financial security. To claim these deductions, you must keep accurate records of your payments.

Factors to Consider While Buying Medical Insurance Plans

Some of the key factors to consider when buying the best mediclaim policy include the following:

  • Age Criteria

    • The age of the insured determines the premium cost for mediclaim insurance. While older people may have higher costs and less coverage because of pre-existing diseases and increased health risks, younger people pay cheaper premiums and are subject to fewer restrictions.

  • Waiting Periods

    • Before claims may be filed, most mediclaim insurance policies contain a waiting period for certain diseases and pre-existing conditions. Depending on the insurer and kind of coverage, the waiting period usually lasts between one and four years.

  • No-Claim Bonus (NCB)/Discount

    • For each year without a claim, insurers increase the amount covered without charging extra by offering a No-Claim Bonus (NCB). Policyholders who stay healthy and avoid filing claims throughout a policy year are rewarded with this incentive.

  • Claim Process and Customer Support

    • Efficient customer service and a seamless claim settlement procedure are essential for hassle-free hospital stays. Quicker approvals and less paperwork are guaranteed by policies with excellent claim settlement percentages and helpful support.

  • Preventive Health Checkup Facility

    • Preventive health examinations are often covered by mediclaim policy plans, which promote early identification of possible health hazards. Annual tests lower the likelihood of serious health issues in the future by assisting policyholders in monitoring their health.

  • Co-payment Clause

    • Co-payment clauses in certain mediclaim insurance plans require policyholders to fork up a portion of the claim amount out of pocket. This lowers premium costs but raises hospitalisation out-of-pocket costs.

  • Cashless Hospitalisation Benefits

    • Policyholders who have a cashless mediclaim coverage can obtain care at network hospitals without having to pay in advance. Financial burden during a medical emergency is eliminated when the insurer pays the hospital immediately.

How Does Medical Insurance Work?

A mediclaim policy protects policyholders against the high costs of healthcare by providing financial coverage for hospitalisation-related medical bills. When admitted to the hospital, the insured has the option of receiving reimbursement in a non-network hospital or cashless care at a network hospital.

After confirming the treatment details and insurance coverage, the insurer pays the hospital immediately for cashless care. All the insured has to do is notify the insurance company and present the necessary paperwork for approval.

In order to make a claim for reimbursement, the policyholder must first pay the hospital costs and then submit medical bills, prescription drugs, and other required paperwork to the insurer. After reviewing the claim, the insurance pays back the qualified costs.

A well-structured mediclaim policy plan covers hospitalisation costs, doctor fees, diagnostic tests, and post-treatment expenses, providing a safety net against unexpected medical emergencies. This ensures policyholders receive timely treatment without financial stress.

Difference Between Mediclaim vs Health Insurance

The table below showcases the difference between a mediclaim policy and a health insurance plan:

Features

Mediclaim Policy

Health Insurance

Scope of Coverage

Covers hospitalisation expenses due to illness or accidents.

Provides comprehensive coverage, including hospitalisation, pre & post-hospitalisation, daycare procedures, critical illness, maternity benefits, and wellness benefits.

Claim

Allows multiple claims up to the sum insured but only for hospitalisation expenses.

Offers multiple claim options, including cashless treatment, reimbursement, and critical illness payouts.

Cover Amount

Generally, a fixed sum is insured with a lower coverage limit.

Higher sum insured options, often customisable as per medical needs.

Difference Between Mediclaim Policy and Critical Illness Insurance Plan

Read the table discussed below to have a detailed understanding of the difference between a mediclaim policy and a critical illness insurance plan:

Features

Mediclaim Policy

Critical Illness Insurance

Scope of Coverage

Covers hospitalisation expenses due to illness, accidents, or surgeries. It reimburses or provides cashless treatment for medical bills.

Provides a lump sum payout upon diagnosis of specific critical illnesses like cancer, heart attack, stroke, kidney failure, etc. The amount can be used for medical or non-medical expenses.

Benefits

Covers in-patient hospitalisation, daycare procedures, and pre & post-hospitalisation costs. Multiple claims can be made up to the sum insured.

A one-time lump sum payout helps cover high-cost treatments, lifestyle adjustments, or income loss during recovery. No hospitalisation is required to claim the benefit.

Waiting Period

Usually 30 days from policy inception, with 2-4 years for pre-existing diseases. Some ailments may have a specific waiting period of 1-2 years.

Typically 90 days from policy start date. Additionally, a survival period of 30 days after diagnosis is mandatory before claiming the benefit.

What is Covered in a Mediclaim Policy?

Read the pointers discussed below to understand the aspects covered under a mediclaim policy plan:

  • Hospitalisation Expenses

    • Room rent, medical consultation fees, surgical costs, medications, and diagnostic tests are all covered by mediclaim coverage. This lowers policyholders' out-of-pocket costs by guaranteeing financial support for both scheduled and emergency hospital stays.

  • Daycare Procedures

    • Dialysis, cataract surgery, chemotherapy, and minor operations are among the therapies that no longer need round-the-clock hospitalisation. Such nursery operations are covered by mediclaim insurance, which guarantees financial support for cutting-edge medical treatments without requiring extended hospital stays.

  • Pre and Post-Hospitalisation

    • For a certain amount of time, medical costs for diagnostic testing and consultations before hospitalisation as well as follow-up care and prescription drugs after hospitalisation are covered. The majority of mediclaim policy plans provide coverage for 30–60 days prior to and 60–90 days following hospitalisation.

  • Ambulance Charges

    • To ensure emergency medical transportation without putting pressure on finances, the mediclaim policy plan reimburses or directly pays ambulance charges. For serious situations, some policies additionally provide air ambulance coverage.

  • Preventive Health Checkups

    • Annual health examinations are included in many mediclaim plans, which aid in early illness identification and preventative therapy. In order to encourage proactive health management, these examinations include blood tests, screenings, and general health evaluations.

What is Not Covered in a Mediclaim Policy?

Following are the aspects that are not covered even in the best mediclaim policy:

  • Pre-existing Medical Conditions

    • The majority of mediclaim insurance plans feature a pre-existing condition waiting period, which usually lasts one to four years. Unless otherwise noted in the policy terms, claims pertaining to certain circumstances are not covered during this time.

  • Certain Types of Treatments

    • Alternative therapies, including homoeopathy, naturopathy, and Ayurveda, are not covered by many mediclaim coverage plans unless they are specifically covered by a rider. Additionally, experimental or untested therapies could not be covered by the policy.

  • Cosmetic Surgeries

    • Cosmetic and aesthetic procedures, such as plastic surgery, Botox, and liposuction, are not covered unless deemed medically necessary due to accidents, burns, or reconstructive surgery for a medical condition.

  • Non-Approved Hospitals

    • Treatments taken at unregistered or non-network hospitals are generally excluded from mediclaim insurance coverage. To ensure claim approval, policyholders should seek treatment at   or network hospitals listed by their insurer.

Documents Required for Buying Medical Insurance

The documents that are necessary to apply for a mediclaim policy are provided below:

  • Identity Proof – Aadhaar, Passport
  • Address Proof –  Voter ID, Aadhaar, Passport
  • Medical Records – If required for health history assessment
  • Income Proof – For high-value policies
  • Mandatory Document- PAN Card

NOTE:  There can be additional documents based on insurer.

Cashless Claim Process for Mediclaim Policy

Policyholders who have a cashless mediclaim policy can obtain care at network hospitals without having to pay in advance. Notify the hospital's insurance desk of your hospitalisation and present your health card and any required paperwork, such as identification documentation and policy details. 

After that, the hospital asks the insurance for pre-authorisation. The insurance company checks the information, evaluates the coverage under the policy, and authorises the claim. After approval, the hospital cost is paid immediately by the insurance, minimising the policyholder's financial burden. Prior to being discharged, the insured is responsible for paying any non-covered costs.

Reimbursement Process for Mediclaim Policy Claims

A Mediclaim policy's reimbursement claim procedure enables policyholders to get care at any hospital and thereafter submit a claim to the insurer for qualified costs.

Hospital bills, discharge summaries, prescription drugs, diagnostic reports, and pharmacy receipts are among the documentation that must be gathered and paid for out of pocket by the insured. Making sure you have the right paperwork is crucial to preventing your claim from being denied.

The policyholder must next provide the insurer with the claim paperwork and a properly completed claim form within the allotted period. Depending on the care obtained, certain insurers might need further documentation.

After reviewing the claim and confirming the information, the mediclaim insurance company proceeds with compensation following the provisions of the policy. If the claim is approved, the insurer transfers the eligible amount directly to the policyholder's bank account.

A well-structured mediclaim insurance policy ensures financial security by covering hospitalisation expenses, reducing the burden of unforeseen medical costs.

Final Words

Overall, a mediclaim policy is a crucial financial safeguard, ensuring access to quality healthcare without straining your savings. Selecting the best mediclaim policy provides comprehensive coverage for you and your family, covering hospitalisation, treatments, and emergencies. With rising medical costs, having mediclaim insurance helps manage unexpected expenses efficiently. Prioritise policies with cashless benefits, preventive checkups, and a smooth claim process to secure your financial well-being during medical crises.

FAQs on Mediclaim Policy

Q. How to choose a Mediclaim Policy?

Compare coverage, premiums, network hospitals, claim settlement ratio, exclusions, and add-ons. Select a policy that meets your healthcare needs and budget.

Q. What are Mediclaim policy benefits?

It offers hospitalisation coverage, cashless treatment, pre- and post-hospitalisation expenses, tax benefits, and financial security against medical emergencies.

Q. Who is eligible for Mediclaim?

Individuals from infants to senior citizens can buy a Mediclaim policy. Eligibility varies based on insurer, policy type, and age criteria.

Q. What are the types of cashless Mediclaim?

Types include individual, family floater, senior citizen, group, and critical illness cashless Mediclaim policies, each catering to different needs.

Q. Does Mediclaim cover accidents?

Yes, most Mediclaim policies cover accident-related hospitalisation costs, emergency care, and surgeries, subject to policy terms and conditions.

Q. What do I need to do after I get hospitalised?

Inform the insurer, submit required documents, get pre-authorisation (for cashless), and retain medical records for claim settlement.

Q. What is a cashless Mediclaim policy?

It allows policyholders to get hospitalised in network hospitals without upfront payments, as the insurer directly settles the bills.

Q. What is the age limit to buy a Mediclaim policy?

The minimum age is 18 years, with some policies covering infants. Maximum age varies, often 65-80 years, depending on the insurer.

Q. Which Mediclaim policy covers dental treatment?

Few Mediclaim policies cover dental treatment, usually under OPD add-ons or specific plans like corporate health insurance or comprehensive policies.

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Francis Rodrigues Francis Rodrigues

Francis Rodrigues has a decade long experience in the insurance sector, and as SVP, E-Commerce and Digital Marketing, HDFC Life, manages the online sales channel, as well as digital and performance marketing. He has had hands-on experience in setting up sales channels and functional teams from scratch over a career spanning 2 decades.

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Vishal Subharwal heads the Strategy, Marketing, E-Commerce, Digital Business & Sustainability initiatives at HDFC Life. He is responsible for crafting and ensuring successful implementation of the overall organisation strategy.

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