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.

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