Individual Mediclaim Policies

Individual Mediclaim Policies

Individual Mediclaim Policies – Mediclaim policies provide for reimbursement of hospitalisation/domiciliary hospitalisation expenses for illness/diseases suffered or accidental injury sustained during the policy period.

What are the expenses covered under this policy?

The policy pays for expenses incurred under the following heads:

  1. Room, boarding expenses in the hospital/nursing home
  2. Nursing expenses
  3. Surgeon, anesthetist, medical practitioner, consultant, specialist fees
  4. Anaesthesia, blood, oxygen, operation theatre charges
  5. Surgical appliances, medicines, and drugs, diagnostic materials and x-ray, dialysis, chemotherapy, radiotherapy, cost of the pacemaker, artificial limbs and cost of organs and similar expenses

Settlement of Expenses

Consider this scenario.

Mr. A has been suffering from malaria and has been hospitalised for a week. On discharge, he received a bill for Rs. 15,000. Who will settle these hospital charges?

If Mr. A had taken the treatment in the network hospital tied up with the Insurance company from which he had taken the mediclaim policy, the bill will be made through Third Party Administrators. This is known as cashless scheme.

If he had taken treatment from any other hospital other than the network hospital, he himself has to make the payment and get it reimbursed from the Insurance company.

Third Party Administrators (TPA) – Those who are licensed by the IRDA and, for a fee, are engaged by the company for the provision of health services.
Reimbursement is allowed only when treatment is taken in a hospital or nursing home, which satisfies the criteria specified in the policy.

The criteria refer to registration with the local authorities, provision of the number of in-patient beds, operation theatre, qualified doctors and nursing staff round the clock.

Expenses on hospitalisation for a minimum period of 24 hours are admissible, subject to exceptions under the policy.

Eligibility for Hospitalisation Expenses under Mediclaim Policies

People taking the following treatments need not be admitted to the hospital for 24 hours. They may finish the treatment/surgery within a day but still be considered as being under the hospitalisation benefit. Such treatments include:

  • Dialysis
  • Chemotherapy
  • Radiotherapy
  • Eye surgery
  • Dental surgery
  • Lithotripsy (kidney stone removal)
  • D&C
  • Tonsillectomy

The expenses can be classified into three phases:

  • Pre-hospital expenses
  • Hospital expenses and
  • Post-hospital expenses

For example, a person may meet the doctor, undergo some clinical tests, and then be advised to take treatment under hospitalisation. After the treatment is over, he will be advised to take some precautions and medicines.

In such cases, relevant medical expenses incurred during the period up to 30 days prior to hospitalisation and period of 60 days after hospitalisation are treated as part of the claim.

Domiciliary Hospitalisation Benefit

There are situations when the patient cannot be taken to the hospital/nursing home for medical reasons. The treatment would be done at the patient’s home itself.

This means medical treatment for a period exceeding 3 days for such illness/injury which, in the normal course, would require treatment at the hospital/nursing home but actually taken whilst confined at home in India under any of the following circumstances:

  1. Patient is in such a condition that he/she cannot be removed to the hospital/nursing home
  2. Patient cannot be removed to hospital/nursing home for lack of accommodation therein

However, this benefit does not cover:

  1. Expenses incurred for treatment for pre and post-hospital treatment and
  2. Expenses incurred for treatment of any of the following diseases:
    • Asthma
    • Bronchitis
    • Chronic nephritis
    • Diarrhea and all types of dysenteries including gastro-enteritis
    • Diabetes mellitus and diabetes insipidus
    • Epilepsy
    • Hypertension
    • Influenza, cough, and cold
    • All psychiatric or psychosomatic disorders
    • Pyrexia of unknown origin for less than 10 days
    • Tonsillitis and upper respiratory tract infection including laryngitis and pharyngitis
    • Arthritis, gout, and rheumatism


  1. Under the policy, anyone illness means the continuous period of illness
  2. It includes relapse within 45 days from the date of the last consultation with the hospital/nursing home, where treatment may have been taken
  3. The occurrence of same illness after a lapse of 45 days will be considered as fresh illness for the purpose of this policy.

Exclusions under Mediclaim Policies

Consider these scenarios.

  • At the time of taking a mediclaim policy, a person has heart problems
  • At the time of taking a mediclaim policy, a person has kidney problems

In such cases, can the person claim surgery charges for the by-pass done under the mediclaim policy?

No. No claim is payable for all diseases/injuries, which are pre-existing when the policy is taken for the first time.

Consider this scenario.

A person has diabetics at the time of taking a mediclaim policy. He has undergone a cataract surgery within one month of taking the policy. Can he claim the charges under the mediclaim policy?

Yes. Any disease contracted by the insured person during the first 30 days from the commencement of the policy is covered under the mediclaim policy.

To sum up:

No claim is payable in respect of the following:

  • All diseases/injuries, which are pre-existing when the policy is taken for the first time
  • For any disease, other than the diseases mentioned below, contracted by the insured person during the first 30 days from the commencement date of the policy
    • Cataract
    • Benign prostatic hypertrophy
    • Hysterectomy for menorrhagia or fibromyoma
    • Hernia
    • Hydrocele
    • Congenital internal disease
    • Fistula in anus, piles, sinusitis and related disorders

If these diseases are pre-existing at the time of proposal, they will not be covered even during the subsequent period of renewal.

Exemption from Exclusion

The above exclusions do not apply:

  1. If in the opinion of a panel of medical practitioners constituted by the company for the purpose, the insured person could not have known of the existence of the disease or any symptoms or complaints thereof at the time of making the proposal for Insurance to the company
  2. If the insured had not taken any consultation or treatment in respect of the hospitalisation for which the claim under the policy is made, prior to taking the Insurance

Other Exclusions

Given here are the other exclusions:

  • Circumcision unless necessary for treatment of a disease not excluded hereunder or as may be necessitated due to an accident, vaccination or inoculation or change of life or cosmetic or aesthetic treatment of any description, plastic surgery other than as may be necessitated due to an accident or as a part of any illness
  • Cost of spectacles and contact lenses, hearing aids
  • Dental treatment or surgery of any kind unless requiring hospitalisation
  • Convalescence, general debility, run-down condition or rest cure, congenital external diseases or defects or anomalies, sterility, venereal disease, intentional self injury and use of intoxicating drugs/alcohol
  • AIDS
  • Charges incurred at hospitals or nursing homes primarily for diagnostic, x-ray or laboratory examination or other diagnostic studies not consistent with the positive existence or presence of any ailment, sickness or injury for which confinement is required at a hospital/nursing home or at home under domiciliary hospitalisation defined
  • Expenses on vitamins and tonics unless forming part of treatment
  • Treatment arising from pregnancy (including voluntary termination of pregnancy) and childbirth (including caesarean section)
  • Naturopathy treatment

Policy Conditions

Let us go through the policy conditions with regard to taking the treatment and submitting the documents for a claim.

  1. Notice of any claim with full particulars shall be sent to the Third Party Administrator immediately and within 24 hours of emergency hospitalisation/domiciliary hospitalisation
  2. All claim documents must be filled with the TPA within 7 days from the date of discharge from the hospital or the date of completion of post-hospitalisation treatment (original bills, receipts and so on must be furnished to the TPA)
  3. Any medical practitioner authorised by the TPA/company shall be allowed to examine the insured person in case of any alleged injury or disease, as may be reasonably required by the company
  4. All treatments shall have to be taken in India and all claims are payable in Indian currency
  5. If the TPA or the company shall disclaim liability for any claim and if the insured shall not within 12 months from the date of receipt of such disclaimer notify the TPA/company that he does not accept such disclaimer and intends to recover his claim, the claim shall be deemed to have been abandoned

More on Mediclaim Policies

Let us see some of the important provisions under the individual medical policies.

Cumulative Bonus

The sum insured is increased by 5% for each claim free year of Insurance, subject to a maximum accumulation of 10 years. In the event of a claim, the increased percentage will be reduced by 10% of the sum insured at the next renewal but the basic sum insured will remain the same.

Cost of Health Check Up

The insured shall be entitled to reimbursement of medical check up once in every four underwriting years subject to no claim being preferred during this period. The cost shall not exceed 1% of the average sum insured during the block of four years.

Note: Both the above benefits apply in respect of continuous Insurance without break. In exceptional circumstances maximum 7 days break is allowed, subject to medical examination.

The sum insured is decided by the insured. The sum insured is usually available from Rs. 15,000 to Rs. 5,00,000. Liability for domiciliary hospitalisation is limited to a percentage of the sum insured.

Sum Insured and Premium

The policy is available to persons between 5–80 years of age.

The premium varies according to the sum insured and the age limit as below:

5–80 years: Up to 35 years/46–55 years/56–65 years/66–70 years/71–75 years/76–80 years

Children between the age of 3 months and 5 years can be covered provided one or both parents are covered simultaneously.

Family Discount

A discount in the total premium is allowed to a family comprising the insured and any one or more of the following:

  1. Spouse
  2. Dependent children
  3. Dependent parents.