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What is Mediclaim Insurance?
Which expenses are reimbursed under this policy?
Who can take this policy?
Can treatment be taken from any Hospital/ Nursing Home?
What is the minimum period of hospitalisation for claiming expenses?
What is the sum insured?
What is the premium?
What is 'Domicilary Hospitalisation’?
What will the policy pay?
What will the policy not pay?
What should be done in case of a claim?
Written by : DoctorNDTV Team
  • What is Mediclaim Insurance?

    Mediclaim insurance is a cover, which takes care of the hospitalisation expenses subjected to maximum sum insured in respect of the following eventualities
    • Sudden illness
    • An accident
    • Any surgery, which is required in respect of any disease, which has arisen during the policy period.
  • Which expenses are reimbursed under this policy?

  • Hospitalisation expenses due to accidental injury / illness / surgery.
  • Domiciliary hospitalisation expenses.
  • Pre-hospitalisation expenses upto 30 days.
  • Post-hospitalisation expenses upto 60 days.
  • Who can take this policy?

  • Any person in the age group of five to 75 years. Children aged three months to 5 years can only be covered along with parents.
  • Institutions (Government or Private) for their employees.
  • Clubs and associations for their members in the specified age group.
  • Group schemes for homogenous groups of more than 50 persons.
  • Domiciliary hospitilisation benefits can be excluded with General Insurance Corporation’s approval and a premium discount availed.
  • Can treatment be taken from any Hospital/ Nursing Home?

    This claim is payable only when the treatment is taken in a Hospital/Nursing Home in India which is either:

    • Registered as a Hospital or Nursing Home with the local authorities, and is under the supervision of a registered and qualified medical practitioner, OR
    • Which complies with the minimum criteria:
    • It has atleast 15 beds
    • A fully equipped operation theatre of its own where surgical operations are being carried out.
    • A fully qualified nursing staff around the clock under its employment.
    • Fully qualified doctor in-charge round the clock.
  • What is the minimum period of hospitalisation for claiming expenses?

    The minimum period of hospitalisation for claming hospitalisation expenses is 24 hours. However, the time limit of 24 hours is not applicable in case of treatment like dialysis, chemotherapy, lithotripsy, radiotherapy, eye Surgery, dental surgery, tonsillectomy, D&C taken in Hospital/Nursing Home.
  • What is the sum insured?

    The range available is from: Rs15,000/- to Rs.3,00,000/-. It can be opted for in multiples of Rs.5,000/-
  • What is the premium?

    The premium depends on the age of the insured and sum insured selected. It ranges from Rs.175/- to Rs.5770/-per annum per person.
  • What is 'Domicilary Hospitalisation’?

    This means medical treatment at home (in India) on the recommendation of the attending medical practitioner for a period exceeding three days for such illness/disease/injury, which in the normal course would require care and treatment at a hospital/nursing home. This is normally applicable when :
    • The condition is such that the patient cannot be removed to a hospital/nursing home, or
    • The patient cannot be removed to the hospital/ nursing home due to lack of accommodation in the hospital/nursing home.
  • What will the policy pay?

    1. Actual hospitalisation expenses, subject to a maximum of Rs. 15,000 to Rs. 3 lakhs, sum insured chosen at the inception of the policy.
    2. Actual domiciliary hospitalisation expenses limited to Rs.3,000 to Rs. 45,000, depending on the sum insured chosen at inception.
    3. Cost of the health check up is reimbursable at the end of four continuous claim free underwriting years.
    4. The sum insured will be increased by 5% as cumulative bonus for every claim free year.
    5. Maternity expenses incurred in hospital or nursing home as in-patient, subject to the limit specified or Rs. 50,000/- whichever is lower will be paid. This will be given on payment of extra premium and policy being limited to cover maternity benefits. All terms, benefits and conditions of the cover are subject to the definitions of various terms under the policy.
  • What will the policy not pay?

    Broadly, the policy will not pay claims under the following circumstances:

    1. Domiciliary Hospitalisation: Pre and post hospitalisation treatment, treatment of asthma, chronic nephritis and nephritis syndrome, gastro-enteritis, diabetes mellitus, hypertension, influenza, cough and cold, all psychiatric disorders, tonsillitis and upper respiratory tract infection and rheumatism or any treatment relating to illness or disease already in existence at the time of proposal.
    2. Any disease or injury during the first 30 days of commencement of the policy (accidental injury is not an exclusion).
    3. In the first year of cover, cataract, benign prostatic hypertrophy, hysterectomy, hernia, hydrocoele, congenital internal diseases, fistula in ano, piles, sinusitis and related disorders or any pre-existing disease or illness, that is not covered during renewal also.
    4. Vaccination, inoculation, circumcision or cosmetic treatment, plastic surgery, dental treatment, unless requiring hospitalisation necessitated due to the accident or as a part of any illness.
    5. General debility conditions, sterility, venereal diseases, intentional self-injury, use of intoxicants.
    6. Any treatment related to pregnancy, childbirth and voluntary medical termination of pregnancy during the first 12 weeks of pregnancy.
    7. Cost of spectacles, contact lenses and hearing aids.
  • What should be done in case of a claim?

  • A Primary Notice of claim should be given to the policy issuing office within seven days of hospitalisation.
  • Final claim duly supported by original documents should be submitted to the company within 30 days of discharge from hospital.
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