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Mediclaim vs. Health Insurance

Mediclaim and health insurance plays a considerable role in the importance of life quality and assurance in India. In light of the country's low ranking on the human life index, it only fits that we talk about ways to preserve life in economical ways.

Many times, these terms are confused for the other. However, there are subtle differences between a mediclaim policy and a health insurance policy. One should always own either of these to ensure continued quality life in light of unfortunate untoward events. This is because mediclaim is a type of health plan that falls under the category of health insurance.

Mediclaim

Mediclaim is a straightforward plan that provides a cover against hospitalisation due to accidents and pre-declared illnesses up to an agreed-upon sum assured. Mediclaim covers hospitalisation and treatment costs and usually are bought to settle expenses incurred during the period spent in a hospital.

Types of Pay-outs in a Mediclaim

There are two types of mediclaim pay-outs available:

Cashless Mediclaim

As the name suggests, cashless mediclaim allows the treatment without the policyholder having to shell out money from his/her pocket. Cashless mediclaim has several procedures for even the simplest of claims and can be availed only at hospitals falling under the insurer’s network of hospitals.

For an insured to claim cashless mediclaim, the claimant would be required to sign a pre-authorisation form available in the premises of the network hospitals and wait for approval from the insurer. The process is lengthy and even the slightest mistake in the form can lead to delays. However, it is purely cashless, and this might be just the thing that saves someone from situations in the events of sudden occurrence.

Reimbursement-based Mediclaim

Mediclaim that offers reimbursement do not rely on network hospitals, hence allowing for the insurer to opt for any hospital according to his/her convenience. As opposed to a cashless mediclaim, reimbursement is done for hospitalisation and treatment costs after it has been paid to the hospital by the insured. In this case, the insured bears these costs and later, within a stipulated time window, submit relevant documents that explain the expenditure and are then reimbursed.

In both cases, it is mandated for the insured to be admitted for at least 24 hours for him or her to be eligible for mediclaim pay-outs, be it cashless or reimbursement-based.

Key features of Mediclaim

  • Cost-effective: Because mediclaim is limited in terms of what they cover, they are affordable
  • The best option in case of emergencies: Mediclaim is useful when confronted with unexpected events like accidents that will burn a hole into your pockets
  • Cashless treatment
  • Tax benefits: Mediclaim is eligible for tax exemption under section 80D of the Indian Income Tax Act

Types of Mediclaim Policies

Mediclaim is offered in many flexible options for one to choose from. Some of these are:

Individual mediclaim plans:

The most common form of mediclaim, individual plans, as the name suggests, cover costs to be incurred by individual policyholders.

Family floater plans:

These plans have one premium to cover the entire family under a single sum assured, which makes it a logical choice.

Group mediclaim plans:

These plans are tailor-made for companies and bulk-cover their employees by providing cover to a group of individuals under a group policy.

Senior citizens mediclaim plans:

Owing to the simplistic design of mediclaim, this can be availed by senior citizens with minimal testing and less rigorous entry age restrictions.

Critical illness mediclaim:

Base plans do not cover critical illnesses. However, a mediclaim that covers medical illnesses does. This includes diseases like cancer and kidney failures.

Overseas mediclaim:

These plans cover the insured in case he/she has encountered an accident outside the country.

Exclusions in Mediclaim

Mediclaim, although handy, comes with exclusions. Some scenarios that mediclaim does not cover are:

  • Pre-existing diseases
  • Sexually transmitted diseases
  • Plastic surgeries
  • Cosmetic surgeries including liposuction
  • Pregnancy
  • Dental procedures
  • Vaccination
  • External aids, like hearing aids or contact lenses.

Factors to consider while choosing a Mediclaim plan:

Like every investment is done after complete analysis, the potential mediclaim policy buyer should keep in mind the pros and cons and choose what comes closest to fulfilling his needs and requirements. Some points to keep in mind while buying a mediclaim are:

Scope of coverage:

A higher sum assured will result in a higher premium. One needs to be sure of what his/her risk factors are before choosing a policy.

Co-pay:

Another feature that makes the mediclaim an even cheaper option is the copay type, wherein, instead of opting to go for full coverage, can opt for paying a certain percentage while the insurer will take care of the rest, hence resulting in lower premiums.

Limits:

Almost all mediclaim have limits of coverage under situations. It would be wise to take a look into what the policy covers and what it does not.

Waiting period:

Most mediclaim comes with a waiting period of 30 days wherein you cannot claim.

The network of hospitals:

Cashless facilities can only be availed at network hospitals.

Riders and add-ons:

Mediclaim does not come with additional rider benefits.

Best Mediclaim in India

Best mediclaim available in India to date are:

Mediclaim

Sum assured

Network hospitals

Aditya Birla mediclaim policy

10 Lakh to 30 Lakh

5000+

Bajaj Allianz mediclaim policy

1.5 Lakh to 50 Lakh

6500+

Bharati AXA mediclaim policy

3 Lakh to 5 Lakh

4000+

Cholamandalam mediclaim policy

2 Lakh to 15 Lakh

6500+

Digit mediclaim policy

2 Lakh to 25 Lakh

5800+

Edelweiss mediclaim policy

5 Lakh to 1 Crore

2500+

Future Generali mediclaim policy

3 Lakh to 1 Crore

5000+

HDFC ERGO Health Mediclaim Policy (Formerly – Apollo Munich Mediclaim Policy)

3 Lakh to 50 Lakh

4721

HDFC ERGO Mediclaim policy

3 Lakh to 50 Lakh

10000+

IFFCO Tokio mediclaim policy

50000 to 5 Lakh

5000+

Kotak Mahindra mediclaim policy

2 Lakh to 1 Crore

4800+

Liberty Mediclaim Policy

Up to 1 Crore

3000+

Max Bupa Mediclaim Policy

3 Lakh to 1 Crore

4115+

ManipalCigna Mediclaim Policy

2.5 Lakh to 50 Lakh

4000+

National Mediclaim Plus Policy

2 Lakh to 50 Lakh

6000+

New India Assurance Mediclaim Policy

1 Lakh to 15 Lakh

3000+

Oriental Individual Mediclaim Policy

1 Lakh to 10 Lakh

4300+

Religare Mediclaim Policy

3 Lakh to 60 Lakh

4987

Royal Sundaram Mediclaim Policy

2 Lakh to 150 Lakh

5000+

Reliance HealthWise Mediclaim Policy

1 Lakh to 5 Lakh

4000+

Raheja QBE Mediclaim Policy

1 Lakh to 50 Lakh

2000+

Star Health Mediclaim Policy

1 Lakh to 25 Lakh

8341+

SBI Mediclaim Policy

1 Lakh to 3 Lakh

6000+

TATA AIG Mediclaim Policy

2 Lakh to 10 Lakh

4000+

United India Mediclaim Policy

1 Lakh to 10 Lakh

7000+

Universal Sompo Mediclaim Policy

Up to 5 Lakh

5000+

Disclaimer: Paisawiki does not endorse, rate or recommend any particular insurer or insurance product offered by an insurer.

Health Insurance

Unlike mediclaim, health insurance plans are much more comprehensive and cover a more significant deal of costs compared to mediclaim. Apart from covering hospitalisation and treatment costs, health insurance plans also provide cover for pre-hospitalisation charges, ambulance charges, and one of the best features called loss of income during the period of hospitalisation.

The majority of health insurance plans only fall under cashless treatment norms under network hospitals. 

Key features of a health insurance

  • Ambulance cover: Health insurances cover ambulance charges which are not covered in mediclaim
  • Post-hospitalisation check-ups: Health insurances cover check-up costs up to a period of 180 days.
  • AYUSH compatibility: Some health insurance companies are compatible with alternate remedies or Ayurveda, Yoga and Naturopathy, Unani, Siddha, and Homeopathy (AYUSH).
  • Pre-hospitalisation expenses: Health insurances cover pre-hospitalization charges like diagnosis, room rent charges, operation theatre costs, ICU costs, consultation fees, surgery charges, etc.
  • Critical illness cover: Available in the form of riders in most of the health insurances, these cover illnesses like cancer, coronary diseases, paralysis, Parkinson’s, etc.

Benefits of health insurance plans

Today, buying health insurance is a cakewalk, and most of the companies sell health insurance online with minimal paperwork. Some benefits of opting for health insurance are:

  • Saves time: Because these policies are available online, it helps in saving time and cuts out middlemen.
  • Readily available information: There are no hidden terms as every bit of information is available online.
  • Comparison using insurance calculators: Most companies will give you the option of using a health plan premium calculator that allows you to select the best plan based on the premium and also compare different plans.
  • Low premiums: Due to the predictable risks involved, the premiums are economically set to cover for unfortunate mishaps.

Types of Health insurance policies

There are a variety of health insurance plans to choose from depending on requirements.

  • Family floater plan: Assuming not every member will fall ill at the same time, the policy covers all members of the family under a shared sum assured.
  • Senior citizenship Health plan: As the name suggests, these types of plans are tailor-made for senior citizens and diseases arising due to old age. In line with IRDA guidelines, insurers are to provide cover till the age of 65 years.
  • Maternity insurance plans: These plans cover for prenatal and postnatal care.
  • Unit-based plans: Not to be confused with market-participating plans, unit, in this context, basically means a specified amount the insured will pay daily to the hospital.
  • Critical Illness plans: Although riders will give you a cover against most major critical illnesses, a critical illness plan is much more comprehensive and operates on Lump Sum benefit and pays a lump sum amount on the diagnosis.

Exclusions in health insurances

Although comprehensive, health insurances, too, have exclusions. Some of these are

  • Pre-existing conditions
  • AYUSH (Not all health plans offer this option)
  • Conditions related to lifestyle choices
  • Cosmetic surgeries
  • Injuries due to war or military operations
  • Injuries due to extreme sports
  • HIV/AIDS
  • Dental treatments

Factors to consider while choosing a health insurance plan

  • Sum assured: As in the case with every insurance policy, a higher sum assured will result in a higher premium. It is always a good idea to keep in mind the risks and then select the sum assured.
  • Co-pay: Although co-pay is available in health insurance policies as well, it depends on what purpose the policy is taken for. Co-pay might not be affordable in some cases as part of the expense is to be shelled out from the insurer’s ends.
  • Exclusions: Most health insurance plans are subject to exclusions because they simply do not fall under the umbrella of scenarios. One must make sure he/she weighs the pros and cons before proceeding
  • Free-Look period: Most health insurance plans come with a free look period of 30 days within which one can even cancel the said policy.
  • The network of hospitals: Although not a huge factor because health insurance plans allow for inter-country transfers, it still is an important point to consider. The wider the network, the better.
  • Riders and add-ons: Some health insurance plans offer as riders what others might have as an in-built feature. Compare and decide.

Best Health Plans in India

Most of the health plans available in India are excellent due to the number of benefits they have to offer. Some of the best in the country are:

Insurance Companies

Health Plans

Sum Insured (Rs.)

Network Hospitals

Incurred Claim Ratio

Aditya Birla Health Insurance

Active Assure Diamond Plan

Up to Rs. 2 Crore

5850+

59%

Bajaj Allianz Health Insurance

Health Guard Plan

1.5-50 Lakh

6500+

85%

Bharti AXA Health Insurance

Bharti AXA Smart Health Insurance Plan 

3-5 Lakh

4300+

 89%

Cholamandalam Health Insurance

Chola MS Family Healthline Insurance

 2- 15 Lakh

6500+

 35%

Digit Health Insurance

 Digit Health Insurance Plan

2- 25 Lakh

 5900+

11%

Edelweiss Health Insurance

Edelweiss Health Insurance Plan

5  Lakh- 1 Crore

 2578+

115%

Future Generali Health Insurance

Future Generali Criticare Plan

1-50 Lakh (18-45 yrs.)

1-20 Lakh (46-65 yrs.)

 5000+

 73%

HDFC ERGO General Health Insurance

Health Suraksha

2 Lakh-5 Lakh

10000+

62%

HDFC ERGO Health Insurance (Apollo Munich Health Insurance)

Health Optima Restore Plan

3 Lakh-50 Lakh

4105+

62%

IFFCO Tokio Health Insurance

Heath Protector Plus

2-25 Lakh

5000+

 102%

Kotak Mahindra Health Insurance

Kotak Health Premier

-

4800+

 47%

Liberty Health Insurance

Health Connect Supra Top-up

 up to 1 Crore

3000+

 82%

Max Bupa Health Insurance

Companion Individual Health Plan

3 Lakh-1 Cr.

4115+

54%

Manipal Cigna Health Insurance

ProHealth Plus Plan

1 Lakh-25 Lakh

4000+

62%

National Health Insurance

 National Parivar Mediclaim Plus

Up to 50 Lakh

6000+

 107.64%

New India Assurance Health Insurance

New India Assurance Senior Citizen Medi claim Policy

1-15 Lakh

3000+

103.74%

Oriental Health Insurance

Individual Mediclaim Health Plan

1-10 Lakh

4300+

108.80%

Religare Health Insurance

Care Health Plan

4 Lakh-6 Crore

4987+

55%

Raheja QuBE Health Insurance

 Health QBE

 1-2 Lakh

3-50 Lakh

2000+

 33%

Royal Sundaram Health Insurance

Lifeline Supreme Plan

5/10/15/20/50 Lakh

5000+

61%

Reliance Health Insurance

Critical illness Insurance

5,7, 10 Lakh

4000+

 14%

Star Health Insurance

Family Health Optima Insurance Plan

1-25 Lakh

9800+

63%

SBI Health Insurance

Arogya Premier Policy

10-30 Lakh

6000+

52%

Tata AIG Health Insurance

Tata AIG MediPrime Plan

2-10 Lakh

4000+

78%

United India Health Insurance

United India UNI Criticare Health Insurance 

1,3,5 Lakh

7000+

 110.95%

Universal Sompo Health Insurance

Individual Health Plan

Upto 5 Lakh

5000+

92%

Disclaimer: Paisawiki does not endorse, rate or recommend any particular insurer or insurance product offered by an insurer.

Comparisons between a mediclaim and health insurance plan

Although there is a very thin line that separates the two, there are some absolute differences that one needs to keep in mind while choosing either. Some of these can be listed as below.

Factor

Mediclaim

Health insurance

Coverage offered

Offers coverage against accidents and pre-existing illness for a specified amount of time

Health insurances are much more comprehensive and offer pre-hospitalisation coverage. They also include a lost income benefit.

Riders

No riders can be availed

Riders in the form of add-ons are available to cover almost every possible event.

Flexibility in coverage

Once bough, mediclaim offer no flexibility in coverage

Flexibility in coverage throughout the term, allowing for reduction of premiums or increasing the sum assured anytime.

Claim pay-out

A mediclaim can be utilized until the sum assured is exhausted

Once every policy term

Hospitalisation

Mandatory

Day-care procedures can be claimed.

In closing, health insurance seems more comprehensive. But a mediclaim is handier for emergencies.

FAQs

  • Q1. What is the difference between a mediclaim and a health insurance policy?

    Ans. In broad terms, a mediclaim is a plan that covers expenses incurred during hospitalisation due to accidents for a limited term. These are usually limited to one year. However, health insurances are much more comprehensive and, in most cases, are lifelong term plans.

  • Q2. Why should one go for mediclaim?

    Ans. With the exponential rise in healthcare prices, it is only logical that one goes for some sort of cover that helps. Mediclaim comes in handy, especially at times when unexpected events unfold.

  • Q3. What does health insurance not cover?

    Ans. It is always important that although health insurance caters to a wider range, they still have their exclusions like dentals, sexually transmitted diseases, drug/alcohol abuse, intentional self-inflicted harm, HIV/AIDS, and naturopathy.

  • Q4. Does mediclaim cover LASIK surgeries?

    Ans. No. LASIK is categorised under cosmetic surgery and is not covered under mediclaim.

  • Q5. What happens if my health insurance lapses?

    Ans. Once a premium date is missed, a grace period of 15 days is rolled out by the insurer. If the outstanding premiums are paid within this period, the policy is renewed. If the insured fails to pay the premium, the policy lapses. Depending on the terms set forth by the company, the policy can be renewed anywhere between six months to up to a year after paying outstanding premiums.

  • Q6. How can one calculate premiums for his/her mediclaim?

    Ans. All insurance companies have a tool known as the insurance premium calculator. By entering a few basic details, one can easily estimate the premium he/she would be paying toward the mediclaim.

  • Q7. How many claims can one make against his/her health insurance?

    Ans. There is no cap on the number of claims one can make as health insurances are lifelong policies. The maximum limit though, is the sum assured. Once the sum assured is depleted, one has to take up another policy.

  • Q8. Does mediclaim cover pre-existing diseases?

    Ans. Yes. However, most mediclaim offer coverage for pre-existing illnesses only after a waiting period of 4 years. Group mediclaim; however, provide cover for pre-existing diseases from day one after the policy is activated. Some insurance companies like Bajaj Allianz, SBI, and ICICI Prudential offer post 2 years of waiting periods.

Written By: Paisawiki - Updated: 10 July 2020

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