What is Covered & Not Covered Under Mediclaim Policy?

A mediclaim policy covers the costs for treatments before and after admission. The insurance policy covers yearly health checks and day-care costs, but does not cover pregnancy, cosmetic surgery, or self-inflicted injuries or pre-existing conditions. Also, premiums for medical insurance are eligible for tax deductions as well. 

Medical procedures are growing costlier by the day. Enrolling in a health insurance or mediclaim policy is no longer optional if you do not already hold one. However, signing up is only half the job. The benefits of health insurance go well beyond hospital bills, and knowing the fine print now saves confusion later. This blog breaks down what mediclaim covers, what it excludes, and why both halves matter equally. 

What is Covered Under a Mediclaim Policy?

These are the various aspects covered under a mediclaim policy:

1. Pre-Hospitalisation and Post-Hospitalisation Costs

Costs related to pre-hospitalisation and post-hospitalisation expenses, like treatment, diagnosis, specialists' charges, medication expenses, and so on, are included in most mediclaim insurance plans.

2. Free of Cost Annual Check-ups

Mediclaim insurance plans can give you access to free check-ups on a yearly basis, depending on the features. They may also include tests for ECG, kidney function, blood glucose, urine tests, and blood groups.

3. Day Care Treatments

Diseases covered under mediclaim likewise cover day care treatment, i.e., you don't need to be admitted to the emergency clinic for 24 hours. Treatments like dialysis, chemotherapy, and cataract are included in this section.

4. Domiciliary Hospitalisation

You may likewise take the benefit of domiciliary hospitalisation for diseases covered under the mediclaim policy, if you are not in a condition to travel to the clinic. You will be reimbursed for any treatments that exceed 3 days under medication, on meeting conditions set by the insurer. 

5. In-Patient Hospitalisation

In case of any health-related crisis, you can get the benefit of cashless hospitalisation for diseases covered under the mediclaim policy. You can avail the treatment without having to pay in cash. Costs incorporated under mediclaim coverage, including room charges, nursing costs, ICU, specialist expense, blood, oxygen, and OT charges, can be paid through cashless mediclaim.

6. Extra Cover

Organ donor cover, ICU charges, NCB, complimentary ambulance service, and second opinions are additionally covered under mediclaim cover. However, these depend on the plan.

7. No Claim Bonus (NCB)

This is a bonus that you can get for not asserting your right to mediclaim cover during any year of your tenure with the company.

8. Taxation Benefits

Premiums paid for a mediclaim policy covering self, spouse, dependent children, and parents are eligible for deduction under Section 126 (previously known as Section 80D) of the Income Tax Act 2025. However, the deductions are only available under the Old Tax Regime. 

What Is Not Covered Under Mediclaim Policy

These are all aspects that are not covered under your mediclaim coverage: 

1. Corrective Cosmetic Surgery

Plastic surgery, cosmetic corrections, and implants are also not covered under mediclaim. 

2. Infertility Treatment

Tests and treatments related to infertility and in vitro fertilisation.

3. Pregnancy

Treatment emerging from or related to pregnancy, child labour, unnatural birth cycle, abortion, etc. 

4. Prior Diseases

Any determination of infections/diseases/event of an occasion, where manifestations initially happen within the initial 30 days from the start date of the mediclaim insurance policy, constitutes diseases not covered under the mediclaim policy.

5. Injuries inflicted due to Alcohol Consumption

Most expenses that are incurred because of or are related to alcohol or medication misuse or abuse.

6. Self-Induced Injuries

Expenses owing to self-caused injuries such as but not limited to suicides, attempted suicide, and suicidal tendencies. 

7. Permanent Exclusions

Hospitalisation costs induced due to mob strikes, riots, war, and nuclear warfare are excluded in your mediclaim insurance.

Additional Considerations for Buying a Mediclaim Policy

Choosing the right policy also depends on the following factors. This is why it is important to read the fine print carefully and consult an insurance expert if needed.

Final Thoughts

These details should help you to make a better and more informed decision while buying health insurance plans or a mediclaim insurance policy. Niva Bupa offers the best health insurance plans, corporate health insurance plans & travel insurance plans in India, offering fast and easy claims to all its customers. Make sure you are choosing the right health insurance plan by opting for Niva Bupa Health Insurance.

Frequently Asked Questions

1. Is there an age limit to buy a mediclaim policy?

 Most insurers allow entry between 18 and 65 years, though several plans now extend coverage to senior citizens well past that mark. 

2. Can a mediclaim policy be ported to another insurer?

Yes, portability is allowed under IRDAI guidelines. The policyholder does not lose accumulated benefits such as waiting period credit or no claim bonus in the process. 

3. What happens if a mediclaim claim gets rejected?

Insurers are required to state the reason in writing. Some of the common causes include: incomplete documentation, policy exclusions, or claims filed after the permitted window.