Mediclaim Insurance

What is Mediclaim Policy?

The MediClaim insurance policy aims to provide reimbursement of hospitalisation expenses incurred as a result of illness/disease/sickness and / or accidental injuries.

Types of Mediclaim Policy

• Individual Mediclaim

• Group Mediclaim

• Critical Illness

• Senior Citizen Mediclaim Policy

• Special Maternity policies

Benefits of Mediclaim policy

• Hospitalisation Cover - In-patient hospitalisation expenses for a minimum of 24hours.

• This includes room rent & boarding @ 2% of sum insured subject to a maximum of Rs.4000/- per day.

• Nursing expenses.

• Surgeon's fees, Consultant's fees, Anaesthetist's fees.

Cont..

• Cost of blood, oxygen, diagnostic expenses, cost of pacemakers.

• Cost of medicines and drugs.

• Emergency ambulance charges for transporting the insured patient to the hospital @ Rs.750/- per hospitalisation and Rs.1500/- per policy period.

Pre-hospitalisation medical expenses up to 30 days prior to date of admission into the hospital.

A lump sum calculated at 7% of the hospitalisation expenses payable towards post - hospitalisation , subject to a maximum of Rs.5000/- per occurrence as per the policy.Non-allopathic treatments up to Rs. 25,000/- per occurrence, subject to a maximum of 25% of Sum insured per policy period.

Mediclaim ensures that you are adequately covered for all your medical expenses which might arise in the future.

The coverage offered by mediclaim policies is different, depending on what kind of policy you choose

Tax Benefits

This plan offers tax benefits for the premiums as a deduction from the taxable income under section 80D of the Income Tax Act.

1. Policy will be provided on Floater basis covering 1 + 5 members in the family. Family means Self, Spouse, 2 Dependent Children's and Parents or Parents in Laws. No siblings to be covered.

2. Upper Age limit shall be 80 years at the inception of the Policy.

3. Sum Insured shall be Rs. 5 Lacs and Rs. 10 Lacs on family Floater basis.

4. For new members 6 months waiting period applicable for pre-existing diseases.

5. 9 months waiting period under Maternity benefits available for new members.

Features of Mediclaim policy

Cont..

• 6. New born babies shall be covered from day 1 to 3 months.

7. Maternity benefit shall be restricted to Rs. 50,000/- & Rs. 1,00,000/- for sum insured for Rs. 5 Lacs & Rs. 10 Lacs.

8. First year exclusion and 30 days waiting waived off.

9. Ayurvedic treatment in Government recognized hospital as an in-patient shall be covered.

10. Emergency ambulance charges up to Rs. 1500/- per case is admissible.

11. Accidental dental treatment shall be covered.

12. Room Rent per day is restricted to 0.5 % of the sum insured for normal rooms and 1 % for ICU.

13. Diseases capping’s as per GMC applicable as under :-

a) Cataract :- Actual Expenses or 25% of the sum insured whichever is less.

b) Hernia :- Actual Expenses or 25% of the sum insured whichever is less.

c) Hysterectomy : Actual Expenses or 25% of the sum insured whichever is less.

d) Major Surgeries : Actual Expenses or 70% of the sum insured whichever is less.

Major surgeries include Cardiac Surgeries, Brain Tumour Surgeries, Pace Makerimplementation for sick sinus syndrome , Cancer Surgeries , Kidney Transplant & RenalSurgeries, Hip, Knee , Joint replacement surgeries.

14. For new joinees, 10% Co-payment shall be applicable in all the claims.

15. Dependents will be allowed only with the primary members except spouse & new born baby,if any for the new joinees.

Incurred loss ratio for existing primary members & also their dependents will be monitored on regular basis.

If this exceeds 100% appropriate additional premium will be paid by the primary members.

In case of non-payment of additional premium by the specific primary members, the cover will be seized for him & dependents.

There are various types of companies providing Mediclaim insurance:

It includes public as well as private companies:

Public:- United India Insurance –Family Medicare facility , National Insurance Mediclaim Policy, etc.,

Private:-Star Health Medicare Insurance, Apollo Munich Mediclaim Policy, etc.,

United India Insurance –Family Medicare facility

UNITED INDIA INSURANCE is one of leading general insurance companies in India, offering a various insurance product to the customers.

Family Medicare Policy is one of products that covers all family members against medical expenses due to any disease or accident.

This MEDICLAIM covers following expenses-

•Room rent, boarding expenses and nursing expenses up to 1% of sum insured per day. It also includes nursing care, RMO charges, IV Fluid/Blood

•Transfusion/Injection administration charges.

•In case of admitted in ICU, the double the sum insured per day.

•Surgeon/Anaesthetists/Consultants/Medical Practitioner/Specialist Fees

•Anaesthetists, blood, oxygen, operation theatre charges, surgical appliances, cost of medicines and drugs, diagnostic materials, x-ray, dialysis,

chemotherapy, radiotherapy, artificial limbs, pacemaker and other similar expenses.

Hospitalization expenses (excluding cost of organ) incurred for donor in respect of organ transplant.

Pre and post hospitalization are covered up to 30 days prior to hospitalization and 90 days after hospitalization.

Critical illnesses are covered under a sub limit of each hospitalization.

Features-

No claim discount of 3% after three continuous claim free policy years, subject to a maximum of 15%.

Cost of health check up at the end of block of every three years where no claims made during the block.

Optional cover such as hospital daily cash benefit and ambulance charges at a nominal extra premium.

National Insurance Mediclaim Policy

 National insurance offers medicalim policy which covers the individual and family under the single policy.

It covers all hospitalization expense fro sickness, illness and accidental injuries. Medicalim policy has been devised under the aegis of the government of India.

The policy covers the hospitalization expenses such as room rent, boarding and nursing expenses, surgeon fees, consultant fees, specialist fees, anesthetises, medical practitioner, operation theatre charges, ICU charges, anaesthesia, cost of blood, oxygen, surgical appliances, diagnostic materials, x-ray, dialysis, chemotherapy, radiotherapy, pacemaker, artificial limbs, cost of organ etc.

Pre-existing diseases are covered after 4 continuous claim free policy years.

Tax Benefit-

Premium paid towards the policy is eligible for tax benefit under section 80D of the Income Tax Act,1961.

Age Limit-

Entry age is 18 years to 59 years and can be renewed up to the age of 80 years. Spouse, dependent children above 3 months to 25 years and dependent parent can be covered under the single policy.

Sum Insured-

Minimum sum insured amount is Rs.50,000/- and can be increased in the multiples of Rs.25,000/- up to Rs.5,00,000/-.

Features-

1.Cashless hospitalization facility through TPA

2.No pre medical examination up to the age of 50 years

3.Cumulative bonus on policy renewal

STAR Health Medi Premier Insurance

The STAR Health Medi Premier Insurance is a mediclaim policy that gives you financial security in case of diagnosis of certain illnesses between the policy term.

The diagnosis may need large of money to be paid at very short notice and that is where this policy is beneficial, apart from providing cover for hospitalization due to illnesses and accidents.

Benefits:-

The policy shares two sections. Section I provides protection against unexpected health care, and Section II ensures a lump sum payment of the sum insured.

Section I

Hospitalisation expenses are covered.

Boarding and nursing expenses.

Surgeon’s fees, Consultant’s fees, Anaesthetist's fees.

Cost of medicines and drugs.

Emergency ambulance charges for transporting the insured patient.

Pre-hospitalisation expenses up to 30 days before the date of admission into the hospital.

Section II

50% Lump-Sum Compensation of the sum assured is provided under Section II in addition to payment of hospitalisation under Section I.

Such hospitalisation expenses would be paid only till the date of diagnosis of the Major Illness.

Only one lump sum payment will be process during the Insured Person’s lifetime no matter how many Major illness or treatments the policyholder has suffered.

Survival Period – To become worthy for lump sum compensation, the diagnosis should be 90 days from the commencement date of the policy.

Apollo Munich Mediclaim Policy

Apollo Munich Mediclaim Policyavailable for individuals and families at very affordable rates.

These plans comes in three variants such as Standard, Exclusive and Premium depending on the premium and benefits offered under the plan.

The minimum sum insured is Rs.1Lakh and maximum is Rs.10Lakh. Standard Plan is a most affordable plan which exclusively starts at Rs.3 per day.

These policies cover insured for in-patient hospitalization expenses such as room rent, boarding expenses, doctor/surgeon/specialist fees, nursing care, operation theater charges, ICU charges, cost of medicines and drugs, blood, oxygen, diagnostic expenses, surgical appliances, pacemaker, etc.

The coverage is also provided for pre and post hospitalization, day care procedures, domiciliary treatment, organ donors expenses, etc.

Additional cover for critical illness is offered under Exclusive and Premium Plan.

Another expenses such as daily cash for accompanying an insured child, maternity expenses, outpatient dental treatment, spectacles, contact lenses, hearing aid, etc.

Cost of health check ups are covered up to 1% of sum insured, subject to a maximum of Rs.5,000/- per insured person and provided only once at the end of a block of every continuous three claim free years.

Optional cover is also offered on payment of additional premium.

Cashless claim hospitalization service is provided at over more than 4200 network hospitals across India, including the 42 Apollo Hospitals.

CLAIM SETTLEMENT PROCEDURES

To provide prompt claims servicing to customers Third Party Administrator (TPA) duly licensed by IRDA are appointed.

Also to directly serve customers Health Claims Management Team ( HCMT) are there in certain areas.

Contact numbers are available on the Health Wise Card/Policy Schedule

Following claims services are provided :

"Cashless Facility" at all our Network Hospitals.

Processing and settlement of claims under the Policy with a time bound approach.

24 hours Customer Helpline Service.

Claim Procedure:

Claims are broadly of two types: a. Reimbursement Claims b. Cashless Claims

General Claim Procedure

As soon as there is a need for hospitalisation, please intimate the HCMT/TPA on 24x7 Customer Helpline number as mentioned in your Health Card/Policy Schedule.

You are required to furnish the following information while intimating a claim:

Contact NumbersPolicy Number (as on the Health Card//Policy Schedule)Name of Insured person who is hospitalisedNature of sickness/accidentDate & Time in case of accident, commencement date of symptom of disease in case of sicknessLocation of accidentThe benefit of choosing our network hospital is that you can avail of "Cashless Facility" while you are hospitalised whereas you will have to settle your hospital bills in the hospital which is outside our network.You have to follow the procedures listed below to get the services in different situations.

Procedures for "Cashless Facility“

"Cashless Facility" is the service wherein you need not pay your hospitalisation bills to the hospital either at the time of admission or at the time of discharge from the hospital.

This facility is available only at our Network Hospitals.

To avail the "Cashless Facility" you need to fill "Cashless request form" available in all the network hospitals.

The hospitals will co-ordinate to get the authorisation from the HCMT/TPA for such "Cashless Facility".

This authorisation along with a copy of the card issued by us needs to be given to the Hospital at the time of admission.

You are also required to carry a Photo ID Card.

Please Note: HCMT/TPA shall authorise "Cashless Facility" at the Network Hospitals in respect of treatments which are covered under the policy.

"Cashless Facility" may be denied by the HCMT/TPA in some of the situations as listed below.

In case of any doubt on coverage of the present ailment/ treatment under the policy

If the information sent by you /hospital is insufficient

The ailment/condition etc. not being covered under the policy

If the request for preauthorization is not sent in time

Denial of "Cashless Facility" is not denial of treatment. You may continue with the treatment, pay for the services to the hospital, and later submit the claim for processing and reimbursement.

Emergency hospitalisation

Step 1. Take admission into the hospital.

Step 2. As soon as possible, Intimate the claim at the call centre, obtain the pre-authorisation form from hospital and get the same filled in and signed by the attending doctor.

Step 3. Fax the pre-authorisation form to the HCMT/TPA along with necessary medical details like investigation report etc. at the number mentioned in your Health Card/Policy Schedule. The hospital will co-ordinate for the same.

Step 4. (Option I)A. If an authorisation for "Cashless Facility" from HCMT/TPA has been receivedAt the time of discharge

You will be required to pay for all such expenses that are not payable as per the terms of the policy.Verify the bills and sign on all the billsLeave the original discharge summary and other investigation reports with the hospital. Retain a Xerox copy for your records

Step 4. (Option II)B. In case "Cashless Facility" has been denied by HCMT/TPAAt the time of discharge settle the hospital bills in full and collect all the original bill documents and reportsLodge your claim with HCMT/TPA for processing and reimbursement

Planned hospitalisation

Step 1. Please co-ordinate with your doctor and the hospital and send all the details about the planned hospitalisation including the plan of treatment, cost estimates etc. to HCMT/TPA.This may be sent at least 2 days prior to the planned admission.

Step 2. (Option I)A. If authorisation for "Cashless Facility" from TPA has been receivedAt the time of admission, present the authorisation letter and photo ID card to the hospitalAt the time of discharge

Pay for those expenses that are not reimbursable under the policyVerify the bills and sign on all the bills.Leave the original discharge summary and other investigations reports with the hospital. Retain a Xerox copy for your records

Step 2. (Option II)B. In case "Cashless Facility" has been denied by HCMT/TPAGet admitted and take treatmentAt the time of discharge settle the hospital bills in full and collect all the original bill documents and reportsLodge your claim with HCMT/TPA for processing and reimbursement.

"Please note that failure to intimate HCMT/TPA as soon as the hospitalisation takes place can invalidate your claim."

Procedures for Reimbursement Claims Emergency hospitalisation

Step 1. Take admission into the hospital.

Step 2. As soon as possible, intimate the HCMT/TPA about the hospitalisation.

Step 3. At the time of discharge, settle the hospital bills in full and collect all the original bills, documents and reports.

Step 4. Lodge your claim with HCMT/TPA for processing and reimbursement, by filling in the claim form and attaching required documents as mentioned in the claim form.

Planned hospitalisation

Step 1. Intimate HCMT/TPA of the planned hospitalisation.

Step 2. Get admitted into the hospital.

Step 3. At the time of discharge, settle the hospital bills in full and collect all the original bills, documents and reports.

Step 4. Lodge your claim with HCMT/TPA for processing and reimbursement.

How to lodge your claim with HCMT/TPA for processing and reimbursement

Within 7 days after discharge, please lodge your claim for processing. While submittiing your claim, please make sure that all the documents listed under the document check list are attached.

Document Check list for Hospitalisation, Domiciliary Hospitalisation & Critical illness claims

Hospitalisation / Day Care Treatment

•First prescription of doctor with commencement date of the symptom of disease

•Treatment papers along with doctors prescriptions

•Investigation reports (X-ray/Scan/ECG, Laboratory etc.)

•Original medical bills and receipt of hospital, doctors, medical shops, diagnostic centre etc. supported by Doctor's advice

•Hospital discharge card, in original

•Copy of FIR (if any in case of accident)

Critical Illness Claims

•Claim form duly completed

•Original Specialist Doctor's certificate confirming the diagnosis and when the symptoms first occurred

•Relevant Investigation reports (Radiology, Pathology etc.) confirming the diagnosis

•Hospital admission & discharge card / certificate

Domiciliary Hospitalisation

•First prescription of doctor with commencement date of the symptom of disease

•Treatment papers along with doctors prescriptions

•Investigation reports (X-ray/Scan/ECG, Laboratory etc.)

•Original medical bills and receipt of doctors, medical shops, diagnostic centre etc. supported by Doctor's advice

•Copy of FIR (if any in case of accident)

•Certificate from attending Doctor/Physician stating the condition of the patient is not permissible for him/her to be removed to Hospital/Nursing Home or documentary proof of lack of accommodation in Hospital/Nursing Home

Please note the above list is only indicative. Also they can ask for additional documents/information if required.

Thank you