FAQ on Health Insurance / Mediclaim

What is Mediclaim insurance?
Mediclaim insurance consists of the reimbursement of hospitalisation and/or domiciliary hospitalisation expenses for any illness/diseases or injury sustained by the insured individual.The policy takes care of medical expenses following Hospitalisaton/Domiciliary Hospitalisation of the insured in respect of the following situations:

• in case of sudden illness,
• in case of an accident
• in case of any surgery which is required in respect of any disease which has arisen during the policy period.

What does 'Hospital' mean with regards to mediclaim insurance policies?
Any institution established for the indoor care and treatment of sickness and/or injuries, which is duly registered and supervised actively by a registered medical practitioner

OR

Any establishment

• With at least 15 patient beds
• With a fully equipped operation theatre of its own if surgical procedures are carried out
• Employing fully qualified nursing staff around the clock
• Having fully qualified doctors in charge around the clock

can be classified as a 'Hospital'.

Note: For Class 'C' towns, the number of beds is relaxed to 10 (ten)
Ayurvedic or institutions practising alternative medicine therapy also qualify as 'Hospitals'

What is meant by 'Hospitalisation'?
Any instance when and where the insured individual is hospitalised for a minimum period of 24 hours can be termed as 'Hospitalisation'.
However, for specific treatment like dialysis, chemotherapy, radiotherapy, laser eye surgery, dental surgery, etc when the patient is discharged on the same day is also considered as 'Hospitalisation'.

What is 'Domiciliary Hospitalisation'?
"Domiciliary Hospitalisation' is any instance when and where the insured individual requires medical treatment for more than three days for an illness / disease / injury that in the normal course would require hospitalisation and is conducted at his or her home within India due to The condition of the patient being such that he cannot be moved to the hospital Lack of hospital accommodation

Are there any other restrictions on domiciliary hospitalisation benefits under Mediclaim ?
Under Mediclaim, the limit of compensation is low and for certain diseases like asthma, bronchitis, diabetes, epilepsy, etc it is not available.

What is 'Any one illness' with reference to mediclaim policies?
'Any one illness' would mean the continuous period of illness, including relapse within 45 days from the last consultation with the hospital where the treatment was taken with respect to any mediclaim policy.

What is meant by Pre-hospitalisation and Post-hospitalisation expenses?
The relevant medical expenses incurred during 30 days prior to hospitalisation are known as 'Pre-hospitalisation expenses'.
Medical expenses incurred for 60 days after hospitalisation are known as 'Post-hospitalisation expenses'.

What are the health check-up benefits available under the mediclaim policy?
The Mediclaim policy provides reimbursement of medical expenses for health check-up at the end of every 4 claim-free years at the rate of 0.1 percent of the Capital Sum Insured.

In case an individual is already suffering from a disease, will Mediclaim still reimburse his or her expenses related to the disease?
The insurance company will not reimburse any expenses related to any disease or injury which already existed at the time of first obtaining the insurance cover.

What are the different benefits that can be claimed under the Mediclaim insurance policy in event of hospitalisation?

• Different heads of benefits under hospitalisation:
• Room boarding expenses by the hospital nursing home
• Nursing expenses
• Surgeon, anaesthetist, medical practitioner, consultants, specialist’s fees
• Anaesthesia, blood, oxygen, operation charge, surgical appliances, medicines and drugs, diagnostic material and x-rays, dialysis and chemotherapy, radiotherapy, pacemaker, artificial limbs and cost of organs and similar expenses
• All the above benefits are limited to the max sum insured

The minimum period of hospitalisation should be for 24 hours. However for certain treatments this limit is not applicable when a package charges are levied for treatment by the hospital.

Are all diseases and injuries covered by Mediclaim ?
There are certain diseases and injuries that are not covered by this policy. These fall under basically 3 categories The injuries or diseases not covered in the first year of operation of the policy are:

• Cataract
• Benign prostatic hypertrophy
• Hysterectomy for menorrhagia or fibromyoma
• Hernia, hydrocele
• Congenital internal diseases
• Fistula in anus
• Piles
• Sinusitis and related disorders

Note: The diseases listed above are only excluded from cover only for the first year of the policy and not afterwards.

The injuries and diseases or medical conditions not covered at all under Mediclaim are:

• Cost of spectacles, contact lenses,hearing aids
• Dental treatment, surgery unless it requires hospitalisation
• Convalescence or rest cure
• Congenital external diseases
• Sterility
• Venereal diseases
• Condition directly or indirectly related to AIDS
• Pregnancy
• Circumcision, unless it is necessary under certain circumstances alone

The injuries and diseases not covered under certain circumstances are:

• Intentional self-injury
• Use of intoxicating alcohol and / or drugs

Diseases or injuries arising in the first 30 days from the commencement of policy (this does not include the diseases excluded in the first year of operation of the insurance policy), however if a medical practitioner named by the insurance company states that the policyholder had no knowledge of the existence of the disease, then it will be covered (this also does not apply if the insured had been covered under this policy or group insurance scheme with any Indian Insurance Company, in the immediately preceding 12 months)

Are the tests prescribed by the doctor be reimbursed under Mediclaim?
All charges incurred at the hospital or nursing home primarily for diagnostic purposes such as X-rays, blood analysis, ECG, etc will be reimbursed only if they are consistent with or incidental to the diagnosis and treatment of the ailment for which the policyholder has been hospitalised and not otherwise.

Can the Mediclaim the insurance contract be cancelled midway?
The policy can be cancelled at any time during the course of its operation. In such cases, the insurance company will refund the premium paid (on the basis of the table provided below) only if no claim has been up to the date of cancellation.

Note: The policy may also be cancelled at any time by the insurance company by giving the insured person 30 days notice through a registered letter sent to the last known address of such person.

Under such circumstances, the insurance company has to refund the premium pro-rata for the un-expired period of insurance. The insurance company is however liable for any claim made prior to the date of cancellation.

What kinds of medical tests are covered by Mediclaim ?
Mediclaim covers medical tests connected with the sickness. Hospitalisation expenses for medical check up only are not covered. There has to be positive existence of diseases to claim under Mediclaim.

Can treatment can be taken at any hospital or at a particular hospital under Mediclaim?
Under Mediclaim, treatment at all the hospitals / nursing homes registered with local authorities is allowed. In case there is no registration with the local authority the hospital should have at least 15 in-patient beds, a fully operational operation theatre, qualified nursing staff and doctor in charge. Only if these conditions are satisfied can the person go to his or her hospital of choice.

What are the criteria for deciding on the best health cover?
Choosing a health cover for yourself must be done after careful analysis of your needs. In case you need a wide cover as also Income tax benefits the mediclaim policy with a family package cover could be a suitable option for you. You may also decide on the major ailments policy with annual, five and ten year cover options offering you a reasonable amount of premium savings.

Those going for a wide coverage as also long term cover about five or ten years can opt for the term hospitalisation policy. This gives benefits that are not available under the normal mediclaim policy. Another convenience this policy offers is the non-requirement of every year renewal of the policy. If you plan to go for a less costlier health cover with tax benefit and limited coverage you could choose the Jan Arogya cover. For those closer to retirement age the long-term retirement benefit plan would be the ideal cover.

How do you decide whether a disease was a pre-existing one or not?
While filling up the proposal form for insurance you need to provide details of the illnesses you have suffered during your lifetime. Such disclosures are important else at a later stage if discovered you could end up losing out terribly. At the time of insurance, you should be aware whether you have any disease and whether you are undergoing any treatment. The insurers refer such health issues to their medical panel to differentiate between pre-existing and newly contracted illnesses.

Is there a minimum time limit for stay within the hospital under Mediclaim ?
Under Mediclaim, the minimum stay within the hospital must be for a minimum of 24 hours. However for dialysis, chemotherapy, eye surgery, etc - the stay can be for less than 24 hours.

Does Mediclaim cover any expenses besides hospitalisation costs ?
Mediclaim covers pre-hospitalisation (limited up to 30 days) and post-hospitalisation (limited to 60 days from discharge) expenses also if they are connected with the sickness / accident for which the hospitalisation takes place.

Under Mediclaim, is the limit of insurance per sickness or annual ?
Under Mediclaim, the amount of insurance is the limit until which the insurance company will pay during any policy period. They are annual limits for all sicknesses / accident during a year.

What happens when the limit of insurance is exhausted under Mediclaim ?
Under Mediclaim, future expenses are not covered during the same policy period however when the policy is renewed, the limit of insurance starts afresh.

Under Mediclaim, does a sickness for which a claim is lodged get covered under a future insurance policy or does it become pre-existent for the next policy term ?
Under Mediclaim, a sickness for which a claim is lodged does not become pre-existent. It is covered provided the policy is renewed within time limits and there is no break in the term of the insurance policy. In case there is a break in the term of insurance (up to 7 days allowed subject to certain conditions) then it will definitely become pre-existent and exclusions will apply.

Can my whole family be covered under a single Mediclaim policy? What is family discount under Mediclaim ?
Yes.Under Mediclaim, when the husband or the wife and children or dependant parents are covered under same policy. In fact a family package discount of 10% is also available.

What are the factors which determine the premium payable under Mediclaim ?
Under Mediclaim, the age and the amount of cover are the factors that decide the premium.

Does Mediclaim offer any advantages on renewal ?
On renewal of Mediclaim for every claim free year. a bonus of five percent per year (maximum 50 percent) is allowed and after four continuous renewals, the cost of medical check up to the extent of one percent of cumulative insurance for the last four years is allowed.

Who will receive the claim amount under Mediclaim if the policyholder dies during the time of treatment ?
Under Mediclaim, the claim amount is paid to the nominee of the policyholder. In case there is no nominee made under the policy, then the insurance company will insist upon a succession certificate from a court of law for disbursing the claim amount. Alternatively, the insurers can deposit the claim amount in the court for disbursement to the next legal heirs of the deceased.