Mediclaim Policy

There are different kinds of health insurance available and they are:

• Individual Health Insurance - It covers the medical expenses of a single person.
• Family Floater Health Insurance- A single sum insured shared by all family members under one plan.
• Senior Citizen Health Insurance- This health insurance is specially designed for people aged 60 years and above
• Group Health Insurance- This is the health insurance which is provided to the employees by their employer.
• Critical Illness Insurance- It covers specific life-threatening illnesses like cancer, heart attack, kidney failure, stroke, etc.
• Top-up Health Insurance- It acts as additional coverage when the base plan coverage gets exhausted.

To purchase mediclaim insurance for you and your family, you need to submit the below documents:

• Duly filled proposal form
• Identity proof
• Address proof
• Medical records are required by the health insurance company

Given below are the benefits of the mediclaim policy

• Mediclaim insurance is one of the affordable ways to combat the rising healthcare costs
• Buying a mediclaim policy can prevent you from financial stress caused by a medical emergency like an accident
• Get the benefit of cashless hospitalization at network hospitals where the insurance company directly settles the bill with the hospital
• Buying a mediclaim policy enables the policyholder to receive tax benefits under section 80C of the Income Tax Act, 1961

Given below are the factors that you need to consider at the time of buying mediclaim insurance

Sum Insured: Sum insured is the maximum coverage that you can receive in the event of hospitalization. Opting for a higher sum insured in today’s times is important as medical inflation is on the rise and so are lifestyle diseases. With a mediclaim policy for you and your family, you will be covered only up to the specified sum insured.

Network Hospitals: You can receive cashless coverage at network hospitals that have partnered with the mediclaim insurance company. This means that at the time of hospital admission, employees don’t have to worry about hospital charges as the bills are directly settled with the insurer. This way, you don’t have to bother about managing funds in times of distress and can easily rely on the coverage offered. Therefore, when buying mediclaim insurance, employers must check on the list of hospitals that the insurance company has partnered with.

Claim Settlement Ratio: This ratio is the amount of claims settled by the insurance company out of the total claims received. Any ratio above 90 is considered to be a good ratio. The claim settlement ratio determines the effectiveness of the company in resolving claims. Hence, checking on this ratio before making the purchase is imperative.

Room Rent limit: this is nothing but the per day cost of occupying a room or bed in a hospital for 24 hours. Mediclaim policies generally come with a room rent limit defined as % of the sum insured or a specific amount which can be Rs.3,000- Rs.5,000 per day depending on the policy sum insured. In case you choose a room that costs higher than the room rent mentioned in the policy then he will have to bear the remaining costs out of your pocket.

Co-payment: When choosing group health cover, you must check on co-payment. With the co-payment clause, you have to pay out a part of the claim out of your pocket. For instance, if the hospital bill is Rs. 1 lakh and the copayment mentioned in the policy is 10% then you have to pay Rs. 10,000 out of his pocket and the remaining amount of Rs. 90,000 will be paid by the mediclaim insurance company.

There are two types of claims available in health insurance through which one can file the claim. One is the cashless claim and another is a reimbursement claim.

Cashless Claim: A cashless claim is a claim that is filed in the insurer's network hospital. It is a facility provided by health insurance where the insurer directly pays the hospital for covered medical expenses. Cashless claims are only available at the insurer’s network hospitals, which have agreements to provide this service.

Reimbursement Claim: A reimbursement claim is a claim in which you have to pay for all your medical expenses during hospitalisation and later on get reimbursed to your registered bank account number. This is typically used when treatment is taken at a non-network hospital or if cashless approval isn’t possible.

Steps to File a Cashless Claim

Follow the below-given steps to file a cashless claim:

1. Choose the Network Hospital

At the time of medical emergencies search for the nearby network hospital of the insurer and get admitted to it. Because only at the network hospital you will get a cashless treatment.

2. Inform the Insurer

Inform your insurer about the hospitalisation.

• For planned hospitalisation- Inform 48 hours before the planned hospitalisation.
• For emergency hospitalisation- Inform the insurer within 24-48 hours of hospitalisation.

3. Submit Pre-Authorization Form

Take the pre-authorization form from the hospital's insurer and submit it to the TPA desk by filling out the necessary information and attaching the document that is asked to be attached.

4. Insurer Approval

Once the insurer approves the pre-authorization, the hospital will proceed with the cashless treatment process.

5. Pay for Non- Covered Expenses

Even in cashless treatment, you have to pay for the non-covered expenses such as consumables or non-approved procedures.

Steps to File Reimbursement Claim

Follow the below-given steps to file a reimbursement claim:

1. Inform Your Insurer

Inform your insurer about your hospitalisation. For planned treatment, you have to inform 3 days before hospitalisation and for emergency hospitalisation inform within 24 hours of hospitalisation.

2. Pay for the Treatment

You have to pay all your treatment expenses from your pocket.

3. Collect Essential Documents

Collect all important documents such as hospital bills, discharge slips, medical reports, doctor prescriptions, etc.

4. Fill Out the Claim Form

Download the claim form from the insurer's official website or get it from their office and fill out the required information.

5. Submit the Claim

Submit the claim form and supporting documents to your insurer, either online or by mail.

6. Claim Status

Check your claim status by visiting the insurer's official website.

Go through the below-given points for choosing the right mediclaim policy for yourself:

1. Evaluate Your Needs

Before purchasing the mediclaim policy always evaluate your needs such as your health, medical history, family medical history, age, lifestyle and budget.

2. Compare Different Plans

Always compare the different plans from different insurers before choosing the plan.

3. Check Sum Insured

Sum insured is the major part of any mediclaim policy, so before choosing any policy always go through its sum insured offered by any insurer.

4. Understand Inclusion and Exclusion

Go through the inclusion and exclusion of the policy to know the coverage offered by the insurer.

5. Network Hospital

Ensure the insurer has a wide network of hospitals in your city, especially near your home.

To purchase mediclaim insurance for you and your family, you need to submit the below documents:

• Duly filled proposal form
• Identity proof
• Address proof
• Medical records are required by the health insurance company