What is Covered & Not Covered Under Mediclaim Policy?

Advancements in medical technology have helped reduce the mortality rate of humans while increasing the recovery rate from any infections or diseases. Although this has seen a sharp rise in expenses of medical procedures by the day. It is hence crucial and essential to enrol for a health insurance or mediclaim policy for yourself, in case you do not have any existing health insurance policy to your name.

Having said that, it is also important for you to know what are the benefits of health insurance and mediclaim policy coverage, the list of diseases covered under mediclaim policy, and what is not included under your mediclaim policy. Here we will detail out the important aspects of mediclaim policy coverage and the diseases covered under mediclaim policy in general and inform you on what they cover and what they exclude.

Aspects Covered Under Mediclaim Policy?

Here we shall look at the various aspects covered under mediclaim policy:

1. Taxation Benefits

Premiums paid for self, spouse, dependent children and parents under mediclaim are absolved from taxation as under section 80 D of the Income Tax Act of 1961.

2. Pre-Hospitalization and Post-Hospitalization Costs

All costs related to pre hospitalization and post hospitalization expenses like the treatment, diagnosis, specialists' charges, medication expenses, and so on are included in mediclaim insurance plans.

3. Free of Cost Annual Check Ups

Mediclaim insurance plans can get you access to free check ups on a yearly basis. It incorporates tests for ECG, kidney function, blood glucose, urine test, and blood groups.

4. Day Care Treatments

Diseases covered under mediclaim likewise covers day care treatment, i.e., you don't need to be admitted in the emergency clinic for 24 hours. Chemotherapy, cataract, dialysis, and so forth are incorporated in this section.

5. Domiciliary Hospitalization

You may likewise take the benefit of domiciliary hospitalization for diseases covered under mediclaim policy, if you are not in the condition to travel to the clinic. You will be reimbursed for treatments exceeding 3 days under mediclaim.

6. In-Patient Hospitalization

In the case of any health-related crisis, you can get the benefit of cashless hospitalization under diseases covered under 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's expense, blood, oxygen, and OT charges can be paid through cashless mediclaim.

7. Extra Cover

Organ donor cover, ICU charges, NCB, elective medicines, complimentary ambulance service, and secondary opinions are additionally covered under mediclaim cover.

8. 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.

Aspects Not Covered Under Mediclaim Policy

Here we shall look at what all is not covered under your mediclaim coverage:

1. Corrective Cosmetic Surgery

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

2. Inherent Diseases

Expenses brought about for congenital illnesses additionally don't get covered under medical. These illnesses or handicaps happen because of birth deformity.

3. Infertility Treatment

Tests and treatment identifying with infertility and in vitro fertilisation.

4. Pregnancy

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

5. Sexually Transmitted Diseases

Medical costs brought about for the treatment of sexually transmitted diseases such as Chlamydia, HPV, HIV, Syphilis, Herpes and other such sexually transmitted illnesses are diseases not covered under mediclaim policy.

6. 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 constitute the diseases not covered under mediclaim policy.

7. Injuries inflicted Due to Alcohol Consumption

Expenses emerging from or relating to alcohol or medication misuse or abuse.

8. Self-Induced Injuries

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

9. Permanent Exclusions

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

Additional Considerations for Buying a Mediclaim Policy

Knowing about the inclusions and the list of diseases not covered under health insurance is not enough. You must also gain an understanding of additional considerations, such as sub-limits, deductibles, waiting periods, claim process and documentation. This knowledge is crucial for choosing the right mediclaim policy and maximising the coverage provided by it. It is important to read the policy documents carefully and consult with an insurance expert if needed to make an informed decision.

Sub-limits and deductibles refer to the maximum amount of coverage provided by the policy for certain expenses. For instance, a policy may have a sub-limit of ₹5,000 per day for room rent, which means that if a patient is admitted to a room that costs ₹8,000 per day, the policy will only cover ₹5,000 per day and the rest will have to be paid by the patient. Similarly, deductibles are the amount that the policyholder has to pay out of their own pocket before the policy coverage kicks in. For instance, if a policy has a deductible of ₹10,000 and the hospital bill is ₹50,000, the policy will only cover ₹40,000, and the policyholder will have to pay the remaining ₹10,000.

Waiting periods refer to the time period during which certain conditions or treatments are not covered by the policy. For instance, a policy may have a waiting period of 2 years for pre-existing conditions, which means that any medical expenses related to pre-existing conditions incurred within the first 2 years of the policy will not be covered. Similarly, maternity expenses may have a waiting period of 9 months to 2 years, depending on the policy.

The claim process involves submitting the required documentation to the insurance company to get reimbursed for the medical expenses incurred. The documentation typically includes hospital bills, doctor's prescriptions, diagnostic reports, and discharge summaries. It is important to submit the documentation in a timely manner and follow the procedures outlined by the insurance company to ensure the smooth processing of claims. Examples of how to file a claim may vary from policy to policy.

Parting Words:

We hope that these details will 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.