Facts about mediclaim insurance policy that may not know

Health Insurances 234 views

Do you know what mediclaim insurance policy means? How to get cashless and reimbursement claims? What you need to do while filing the claim? If you do not know these, then this post is for you. Mediclaim insurance policy is an investment that helps you get the access of cashless treatment in the network hospitals of your health insurer. In cashless treatment, you do not have to bear the expenditure for the treatment as the same is done by the insurer. But in case you get yourself treated at a hospital other than the network, then you will have to the bear the expenditure, which can be reimbursed by your insurer after you file the claim. But before you take the mediclaim policy, you must consider the below mentioned points.

Points to keep in mind

Pre-existing conditions or diseases

Do not hide anything about the pre-existing conditions or diseases while buying the mediclaim policy. If you do not do so, your claim may not get approved when you require it. Pre-existing diseases are the ailments, like diabetes, blood pressure or others, which you may have during the time of buying the mediclaim policy. The cover for pre-existing diseases is ensured after the continuous renewal of the policy for 3-5 years. But you can find some insurers giving the cover for some pre-existing diseases from the first year itself.

Mediclaim policy Gets Renewed Every Year

Mediclaim policy is reviewed and renewed every year. If you have made a claim in the first year, then the premium amount may get raised in the subsequent year after the review and renewal of the policy. However, the hike in premium also depends on the amount of claim made by you. In case the amount turns out to be a nominal one, then the premium may not go up. But you have to contend with the waiting period clause, which are there in the policy of most health insurers, before filing the claim. Waiting period means the amount of time that may have to wait before you can make the claim. The period can range from 30 days to 90 days. Keep that in mind and select the mediclaim plan carefully.

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Premium Amount to Increase with Age

As you grow older, you are expected to pay a higher amount of premium compared to when you will be younger, as per the mediclaim insurance policy. Unlike life insurance policy where one can pay a fixed sum of premium throughout the term, one has to pay higher premium with the mediclaim policy once you grow older.

Reimbursements Given in Case of Hospitalization Only

You get reimbursements in case of hospitalization only as per the mediclaim insurance policy. Hospitalization must be for a minimum period of 24 hours. Thus, day care procedures, which require hospitalization for less than 24 hours, are not covered under the mediclaim insurance policy. But there can be exceptions as you may find some policies providing the cover for day care procedures.

Age for Renewal

Mediclaim will cease to exist after you cross a certain age. The policy, which you may have taken during the time when you would be within the age of 20-35 years, may not work when you will cross the age of say 65 or 70 years. There may be few insurers providing an upper limit of 75 years. But generally, it's not the case. So, you are required to opt for a separate mediclaim policy for senior citizens with a higher age limit.


You must carefully read the fine print of the mediclaim policy and check the sub-limits. You can claim the sum assured in a particular year. But, you have to contend with various sib-limits that come with the sum assured amount. The sub-limits could be the permissible amount of expenses  for which you can get the cover. The expenses include room rent, doctor's fee and cost of medicines & drugs. For example- You had to bear a cost of Rs 2,00,000 for a certain surgical procedure with hospitalization for say 4 days. And if your mediclaim is for Rs 4,00,000, then don't think that the entire expenses will get reimbursed as there will be sublimits as mentioned above. Suppose you paid a room rent of Rs 28,000 at Rs 7,000 for 4 days. However, if the sub-limit for room rent is Rs 5,000, then only Rs 20,000 will be reimbursed and not Rs 28,000. Similarly, doctor's fee and other expenses will get reimbursed based on the sub-limits.

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You may not get the cover for maternity expenses in most of the mediclaim policies. But if you manage to get the cover, it will apply only after three years of paying the first premium.

So, these were the points that you need to consider while opting for mediclaim insurance policy. Now get down to know what you are required to do while filing the mediclaim.

Steps for Filing a Mediclaim

  • Intimate the insurer within 24 hours of hospitalization
  • Maintain a chronological order of the bills, reports and receipts.
  • The documents must have the signature of the doctor, the name of patient, cost price, serial number and document number.
  • Ask for a claim form from the health insurance company. Also, you can also download the claim form from the website of the insurer. Read the instructions, given on the form, carefully and fill in the details accurately.
  • The claim form must bear the signature of patient as well as the doctor who executed the treatment along with the seal of the hospital.
  • Ensure you attach relevant policy and medical documents along with the claim form. Make copies of all the documents and review them carefully. Upon missing of any document, the claim may get rejected by the insurer. You must mention correctly the name of Third Party Administrator (TPA) while submitting the documents. You can contact your insurer to get the name of the TPA.

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