Categorized | Health Insurance

mediclaim aspects you must know

A 2011 Survey done by Prayas and Oxfam India covering Assam, Jharkhand, Rajas-than, Tamil Nadu, Uttarakhand and Bihar revealed that average cost of hospitalizing a person rose from Rs.6200 in 2004 to Rs.13450 in 2011. Further, around 13.7 % of a family's household expenditure is being spent on health care where anything above 10% is considered catastrophic expenditure. This means buying a Health Insurance Policy is the safest way to ensure medical care does not suffer due to financial constraints.

Why Mediclaim?

  • Mediclaim will help you spend lac's of rupees in a year for treatment even if one does not have ready cash. Just pay your premiums on time and healthcare will get De-linked from one's financial position.
  • Different types of health insurance policies are available in the market. You can get a plan that offers comprehensive Coverage worth lacs of rupees for all your family members thereby reducing healthcare worries to zero. Presence of private and government insurers means you can compare different deals and choose the Mediclaim policy that suits your requirements.
  • From allopathic treatment in government hospitals to OPD expenses; from hospital room rent to income lost due to illness- you can cover all financial consequences of an illness.   
Mediclaim Options Available In India
  • A standard health insurance policy offers coverage for one individual only. The coverage amount can vary from person to person. The buyer has the option of choosing a high value health insurance policy for aged individuals and cheaper low value coverage for young and healthy family members.
  • This option is not very popular for those seeking family coverage. Buying multiple policies of varying coverage amounts is a complicated process. Coverage cannot be shared and this will lead wastage of coverage and the Premium paid.
  • If one member has used Rs.50,000 on a Rs.2 lacs policy and the other member has spent Rs.3 lacs on a Rs.2 lacs policy, the latter will have to spend the excess sum of Rs.1 lac out of savings despite the fact that coverage worth Rs.1.5 lacs is available for the former member.
  • To overcome this complication, health insurance companies offer family floater plans. Instead of buying two policies of Rs.2 lacs, the buyer can go in for a single floater mediclaim policy worth Rs.4 lacs. If one family member spends Rs.3 lacs, then the other member can utilize the balance coverage of Rs. 1 lac and avoid extra cash outflow.

These individual or family floater plans normally cover expenses related to:
  •  Pre Hospitalization
  •  Hospitalization
  •  Post Hospitalization
  •  Emergency Assistance
  •  General Health Checkups

Insurance companies offer specialized options where one can pay an extra sum over and above the policy premium to cover additional Risk like:
  •  Critical illnesses
  •  Accidents
  •  Disabilities
  •  Women centric illnesses

Mediclaim Settlement
Unlike life or travel insurance, health insurance claims are far more common and can involve numerous complications if not handled properly. Mediclaim settlement can be divided into two categories:

Cashless Mediclaim Settlement
Health insurance companies have tie-ups with hospitals and encourage policyholders to seek cashless treatment in network hospitals. The Policyholder just has to provide policy details when seeking treatment and pay the deductible. The TPA acting on behalf of the health insurance company will settle the Claim amount directly with the hospital.

Reimbursement of Treatment Costs
It is not mandatory to seek treatment in a networked hospital. The option of cashless claims is not available with a hospital outside the insurer's network. The Insured will have to pay for treatment and can seek Reimbursement from the health insurance company. Such claims are normally settled within three weeks.

Role of TPA
In both cases, the claims are routed through the Third Party Administrator. The TPA acts as a bridge between insurance company and policyholder. It receives claim details from the insured. It analyzes the claims and compares it with reasonable market costs to determine whether the claim should be accepted, accepted in part, or rejected. The decision is passed on to the mediclaim provider. TPAs specialize in claims management and ensure complicated claims are processed quickly for the mutual benefit of parties involved.

Mediclaim insurance premium is eligible for deduction worth Rs. 15,000 u/s 80D. Tax benefits apart, health insurance helps take care of expensive and unavoidable medical expenses by paying a small fraction of the amount as mediclaim premium. This is the biggest benefit of having adequate health insurance protection.