Indian Mediclaim Insurance Benefits

There are several insurance companies in India who offer different types of mediclaim insurance policies. The benefits offered by these insurance companies can vary. Insurance customers can quickly compare the details of benefits offered under Indian mediclaim insurance policies.

Health Insurance Benefits

In-patient Treatment

This covers treatment expenses for the insured when they are admitted in a hospital for atleast 24 hours. They are considered In-patients and all expenses following an accident or sickness are covered under Health Insurance. Many insurance plans cover only in-patient treatment.

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Hospital Room and Board (Room Rent)

Room rent or Hospital Room Board is nothing but the per day bed or room charges that hospital asks the patient to pay. With a health insurance cover your room rent is settled by your insurance company in full or upto a limit that is defined in the policy.

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Intensive Care Coverage

This coverage is for expenses incurred by the insured while in the Intensive Care Unit (ICU) during inpatient hospitalisation. This is normally a sub limit under the overall In hospitalisation Medical Expenses.

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Prescription Drugs Coverage

This coverage is for expenses incurred by the insured for Prescription Drugs during inpatient hospitalisation. This is normally a sub limit under the overall In hospitalisation Medical Expenses.

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Surgery Charges Coverage

This coverage is for expenses incurred by the insured for undergoing a covered Surgery during inpatient hospitalisation. This is normally a sub limit under the overall In hospitalisation Medical Expenses.

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Ambulance Expenses

Ambulance insurance is insurance cover that covers the cost of an emergency ambulance if one is needed for the transportation of the insured from and to the hospital after and before being treated in a hospital. Most insurance plans offer a fixed limit towards Ambulance expenses.

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Day Care Procedures

Day-care treatment refers to medical treatment and/or surgical procedure which is undertaken under general or local anaesthesia in a hospital/day care centre in less than 24 hours which would have otherwise required hospitalisation of more than 24 hours. This treatment is due to advanced technology available at most medical facilities across the country.

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Pre-Hospitalization Expenses

Medical expenses incurred by the insured before hospitalisation. It is important to note that unless the expenses incurred before hospitalisation are for the same ailment as when the insured is hospitalised, only then the expenses will be covered. Most plans offer cover for 30 / 60 days for Pre-Hospitalisation.

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Post-Hospitalization

Medical expenses incurred by the insured after hospitalisation. It is important to note that unless the expenses incurred after hospitalisation are for the same ailment as when the insured is hospitalised (follow up medical expenses), only then the expenses will be covered. Most plans offer cover for 60 / 90 days for Post-Hospitalisation.

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Domiciliary Treatment

Sometimes it is not possible to move the patient to a hospital because of their condition or lack of accommodation at the hospital. In such cases, the patient can be treated at home. This is called domiciliary hospitalisation. Medical expenses for such cases will be covered if the treatment continues for a defined period as per the policy coverages.

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Pre-existing Coverage / Disease

A pre-existing disease is any condition, ailment or injury or related condition(s), for which the insured person had signs or symptoms, and /or were diagnosed, and / or received medical advice / treatment within a defined period prior to 1st health insurance policy is issued under which the insured person was covered. Plans offer different waiting periods for Pre existing conditions from 24 months to 48 months.

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Out Patient Treatment (OPD Expenses)

Outpatient treatment refers to any diagnostics, consultations or treatment where a hospital admission is not required. It will often begin from an initial investigation following a referral from your family physician and can be for a consultation involving blood tests, x-rays, MRI scans and so on. Some insurance plans offer coverage upto a defined limit for OPD expenses.

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Diabetes Expenses

This coverage is for expenses incurred by the insured for the specific treatment of Diabetes as an inpatient or outpatient. This is normally a sub limit under the overall Medical Expenses offered under the plan.

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Top-up Plans

These are specific types of health insurance plans, where the insured already has a base insurance policy and wants an increase coverage. The deductible under this Top-up policy is specifically equal to the sum insured of the existing base policy.

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Third Party Administrator (TPA)?
A third-party administrator is an organization that processes insurance claims or certain aspects of employee benefit plans for an Insurance company. It is also a term used to define organizations within the insurance industry which administer other services such as claims administration, customer service. They are registered with IRDAI. The most common services offered by almost all TPA’s in India include:
  • 24 X 7 assistance to all policy holders through toll free numbers
  • Online assistance during hospitalization and filing of claim documents by the insured
  • Cash Less service facilitation at network hospitals up to limit authorized by the insurance company
  • Assistance in providing Ambulance Services during Emergency
  • Preparing and Managing Medical Enrolment Cards for all insureds against their policy for accessing to TPA services and getting admission into network hospitals
  • Claims Processing and Reimbursement for non-network hospitals

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Baby Day One cover

A New Born Baby is covered for any Illness or Injury from the date of birth till the expiry of this Policy, within the terms of this Policy. Any expense incurred towards post natal care, pre–term or pre–mature care or any such expense incurred in connection with delivery of such New Born Baby would not be covered. Congenital External Anomaly of the New Born Baby is also not covered under the policy. No coverage for the New Born Baby would be available during subsequent renewals unless the child is declared for insurance and covered as an Insured Person.

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Consumables Benefit

Some Health insurance policies pay for expenses incurred, for consumables which are listed in ‘Items for which optional cover may be offered by insurers’ under ‘Guidelines on Standardization in Health Insurance, 2016’, which are consumed during the period of hospitalization directly related to the insured’s medical or surgical treatment of illness/disease/injury.

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High End Diagnostics

Some insurance plans will pay the insured for the following diagnostic tests on OPD basis if required as part of a treatment subject to defined limits per policy year annually: a)Brain Perfusion imaging, b)CT guided Biopsy, c)CT Urography, d)Digital Subtraction Angiography (DSA), e)Liver Biopsy, f)Magnetic Resonance Cholangiography Scan, g) PET CT scans, h)PET MRI scans, i) Renogram

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Ayurvedic Coverage

Health insurance for Ayurvedic treatment is a common requirement these days. To cater to the diverse Ayurveda insurance needs of individuals, health insurance companies are offering health insurance with Ayurvedic treatment benefit.

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Low premium plans

Some insurance plans will provide Low premium plans give high cover at low price

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Dental Coverage

This coverage is for expenses incurred by the insured for the specific expense incurred for Dental treatment as an inpatient or outpatient. This is normally a sub limit under the overall Medical Expenses offered under the plan but also offered as a stand alone benefit with a defined sum insured. This normally covers routine dental expenses.

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Maternity Coverage

The medical expenses traceable to childbirth (including complicated deliveries and caesarean sections during hospitalisation) as well as the expenses incurred towards any lawful medical termination of pregnancy during the policy period will be covered.

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Health Check-up

Wikipedia explains the meaning of Preventive Health Check Up perfectly as “Preventive healthcare (alternately preventive medicine or prophylaxis) consists of measures taken for disease prevention, as opposed to disease treatment“. Health, disease, and disability are dynamic processes which begin before individuals realize they are affected. Disease prevention relies on anticipatory actions that can be categorized as primary, secondary, and tertiary prevention. Under section 80D, there is a defined limit of ₹5,000 per year for the insured, his/her immediate family and parents.

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Compassionate Travel

In the event the Insured Person is Hospitalized for more than Five consecutive days in a place where no adult member of his immediate family is present, coverage is available for expenses related to a round trip economy class air ticket, or firstclass railway ticket, to allow the Immediate Family Member be at his/her bedside for the duration of his stay in the hospital. The expenses must be incurred within India and shall not exceed the specified limit during a policy year.

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Critical Illness Benefit

For enhanced protection, an optional coverage against major critical illnesses like Cancer, Open Heart surgery, Kidney Failure, Strokes etc. is available. Upon first diagnosis of any of these illnesses you get an additional coverage as a one time lump sum payout. This payment will be over and above your hospitalisation expenses which are paid through the base policy. This cover can be opted by any member of your family who is aged 18 years or above. Each insurance company offers a defined list of Critical Illnesses that can be opted for by the insured on payment of additional premium.

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AYUSH Benefit

The medical expenses for in-patient treatment taken under Ayurveda, Unani, siddha and homeopathy. This is offered upto the Sum Insured under the health insurance plan.

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Personal Accident Benefit

For increased protection, an optional coverage against Personal Accident is available, which covers the insured against Accidental Death (PA), Dismemberment (DM) and Permanent Total Disability (PTD) following an accident. Upon the unfortunate occurrence of any of these, the insured gets an additional coverage as a one time lump sum payout upto the defined sum insured for this coverage. This payment will be over and above your hospitalisation expenses which are paid through the base policy. This cover can be opted by any member of your family covered under the plan.

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Wellness Solutions

Some health insurance plans comes with an inbuilt package of Wellness Solutions. These offer discounts on various medicines at defined medical stores/chemists, value-added wellness services which are usually online including medical counselling, discounts at fitness studios etc.

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Cashless Treatment/Hospitalisation

It means a facility extended by all insurance companies to the Insured where the payments, of the costs of treatment undergone by the Insured in accordance with the Policy Terms and Conditions, are directly made to network provider by the health insurance Company to the extent pre-authorization approved. These expenses are covered till the sum insured subject to admissibility of the claim. It is important to note that all insurance plans offer cashless treatment only at the designated hospitals which are part of the company hospital network.

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Refill / Restoration / Reinstatement Benefit

When the insured contracts the same or different illness in the same policy year, for which a claim is paid and the sum insured is utilised, the insurance company then refills the policy sum insured for the insured. For example if the Sum Insured (SI) under an individual’s policy is ₹5 lacs and the insured has a claim for ₹4 lacs, without the Refill benefit the remaining policy period will carry a SI of only ₹1 lac…with the Refill/Restoration benefit, the SI for the remainder is re-filled and made available upto ₹5 lacs again to the insured.

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Hospital cash

This policy covers numerous ‘non-medical’ expenses such as incidental expenses at the hospital, transportation, attendant’s cost and other daily expenses that one may not be able to foresee while the insured is hospitalised. This is a fixed daily benefit payable to the insured for the number of day he/she is in hospital.

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E-consultation

Under this benefit offered in some specific plans, the insured gets the option to have unlimited tele/online consultations with qualified doctors. This is a benefit offered under the plan free of cost to the insured.

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Premium Waiver Benefit

If an insured policy holder passes away or is diagnosed with a specified illness during the policy period, then the premium for next year will be waived but the coverage will still be in force.

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Co-Payment

Co-payment is a cost-sharing requirement under a health insurance policy, where the Policy Holder / insured will bear a specified percentage of the admissible costs for a covered benefit. This is defined under the terms and conditions of the policy. There are provisions available under certain insurance plans which allow the insured to pay additional premium for a removal of co-payment, or opt for a higher co-payment for a reduction in premium.

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Waiting period

A waiting period is the length of time you, the insured, will have to wait before the benefits under the health policy can be utilised to the extent of the sum insured. There is a mandatory waiting period of 30 days for all benefits (except Accidental expenses) and then other benefits/coverages come with varying waiting periods upto 48 months.

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Free Look Period

A ‘Free Look Period’ is a period of 15 days from the date of receipt of the policy that a policyholder, in this case you, have to review the entire health insurance plan. If you disagree with any of the terms or conditions mentioned in the policy, you have the option of returning the policy by stating the reasons for the objection. Following this, you are entitled to a refund of the premium paid, provided no claim has been made under this mediclaim insurance policy (subject only to a deduction of the expenses incurred by the company on medical examination and the stamp duty charges). Please note that this facility is not applicable on renewal and portability cases.

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Bariatric Surgery Cover

This coverage is for expenses incurred by the insured for undergoing specifically a Bariatric Surgery during inpatient hospitalisation. This is normally a sub limit under the overall In hospitalisation Medical Expenses. Bariatric surgery is covered under medical advice, subject to certain terms and conditions.

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Family Floater Plan

This is one single health insurance policy that takes care of the hospitalization expenses of your entire family. Family Floater Health Plan has a single sum insured for the entire family that takes care of all the medical expenses during sudden illness, surgeries and accidents for any of the covered family members. It is recommended to have a family floater for the younger family members, while insuring the senior family members under individual plans.

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Grace Period

A grace period refers to a period of 30 days immediately following the premium due date of the medical insurance policy. During this period you can pay the premium of your expired policy and avail continuity benefits such as waiting periods and coverage of pre-existing disease.

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Reasonable and Customary charges

Reasonable and customary charges refer to the expenses incurred for medical services/supplies as long as they are the standard charges for the specific provider and consistent with the prevailing charges in the geographical area for identical or similar services. We also take into account the nature of the illness/injury involved.

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Emergency Assistance Services

These services like medical referral, air ambulance, medical repatriation, compassionate visit, etc are offered complimentary to the insured, so that at no moment one ever feels that healthcare is far away. They can avail of these benefits any number of times during the policy year.

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Lifelong Renewability

Today all the health insurance plans, assures the insured renewability for life without any extra loadings based on the claims.

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Organ Donor expenses

These are expenses incurred by the organ donor. Coverage is for Medical expenses on harvesting the organ from donor during transplantation.

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Cumulative bonus

This is a bonus awarded at the end of each claim free policy period. If you don’t make any claims on your policy for a year, you earn a cumulative bonus % on the base sum insured, at no extra cost. However, the cumulative bonus can be accumulated equal to the amount of base sum insured.

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Tax Benefits
Tax deduction is allowed for health insurance premium payments and such tax benefits can be taken by an Individual. Tax deduction under section 80D is allowed only to an Individual or HUF (Hindu Undivided Family), a Resident or Non-resident citizen of India. In terms of section 80D, tax deduction is allowed for the premium amount paid as insurance premium to cover the health of the individual, his/her spouse, children and parents. It does not matter whether children or parents are dependent on you or not. Under this section, health insurance premiums, contributions to the Central Government Health Scheme, and preventive health check-up can be claimed for a tax deduction. The premium paid against a health insurance policy is exempted from taxation. Hence it effectively:
  • Protects yourself and your family during a medical emergency by offering coverage for hospitalisation expenses and
  • Saves money for you through the income tax deductions under section 80D

Table showing Maximum Amount of Tax Deduction U/S 80D

Insured’s Details IT Deduction under section 80D Exemption for Preventive Health Check Up Total Eligible Tax Deduction
Self + Family ₹25,000 ₹5,000 ₹30,000
Self + Family + Dependent Parents < 60 years ₹25,000 + ₹25,000 ₹5,000 ₹55,000
Self + Family + Dependent Parents > 60 years ₹25,000 + ₹50,000 ₹5,000 ₹80,000
Self (>60 years) + Family + Dependent Parents > 60 years ₹50,000 + ₹50,000 ₹5,000 ₹1,05,000
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