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1.1.

INTRODUCTION OF MEDICLAIM INSURANCE

Mediclaim insurance is an Insurance coverage to claim reimbursement of medical treatment bills


generated due to Health realted hospitalisation.

There are two different ways to get your bills claimed either by cashless facility i.e your bills are
directly paid to the hospital or you can pay your bills in the hospital and get an reimbursement after
submission of the same to the insurance company. Mediclaim policy is a essential for the peoples
because it saves financial loss in case of hospitalization for any sickness, disease or accident. But it
costs much higher than other insurance and is rising in proportion with the rising cost of treatment
available in private hospitals.

We all are aware about the state of medical facilities available in government operated hospitals and
the increased treatment cost in private medical facilities. Medical treatment expenses are very high
and they are increasing everyday.Mediclaim comes to the rescue of a policy holder as a protection
to absorb the cost of treatment when the disease is identified and needs to be treated in hospitals
after admitting the person.

The latest family mediclaim insurance is ideal solution to save money and cover entire family under
single sum insured. This means no more multiple premiums and no more financial strain.
A mediclaim or a health insurance policy provides for reimbursement of hospitalization. If for some
reason, an individual is on bed at and needs an attendant or a nurse, the mediclaim policy will cover
the expenses.

Expenses associated with treatments such as dialysis, chemotherapy, radiotherapy etc are
also covered by the mediclaim policy. If an individual is taken to a hospital or a nursing home and
the insured person-patient is discharged on the same day, the treatment will be considered to be
taken under ‘Hospitalisation Benefit Scheme’. This policy is available in two variants - short term
and long term and the coverage level is similar like other traditional mediclaim policies. It provides
covers for hospitalization expenses for illness and diseases. It includes expenses for doctors fees,
nursing expenses, medicines, blood, surgical appliances and other related expenses.

It is very important for you to check what all is covered by a mediclaim policy. Any disease or
sickness existing before the mediclaim is taken will not be covered. Each mediclaim policy has a
list of specific exclusions. Check the list before you make a purchase. Most Insurance Companies
do not offer mediclaim for obesity related illnesses, expenses arising from HIV or AIDS or the use
of alcohol or drugs and expenses due to attempted suicide. Expenses associated with the treatment
due to war, riots or a terrorist attack is also not insured by policies.

1.2. PRINCIPLES OF MEDICLAIM INSURANCE

Indemnity

A contract of insurance contained in a fire, marine, burglary or any other policy (except life
assurance and personal accident and sickness insurance) is a contract of indemnity. This means that
the insured, in case of loss against which the policy has been issued, shall be paid the actual amount
of loss not exceeding the amount of the policy, i.e. he shall be fully indemnified. The object of
every contract of insurance is to place the insured in the same financial position, as nearly as
possible, after the loss, as if he loss had not taken place at all. It would be against public policy to
allow an insured to make a profit out of his loss or damage.

Utmost Good Faith

Since insurance shifts risk from one party to another, it is essential that there must be utmost
good faith and mutual confidence between the insured and the insurer. In a contract of insurance the
insured knows

More about the subject matter of the contract than the insurer. Consequently, he is duty bound to
disclose accurately all material facts and nothing should be withheld or concealed. Any fact is
material, which goes to the root of the contract of insurance and has a bearing on the risk involved.
It is only when the insurer knows the whole truth that he is in a position to judge

(a) Whether he should accept the risk and


(b) What premium he should charge.

If that were so, the insured might be tempted to bring about the event insured against in order to get
money.

Insurable Interest

A contract of insurance affected without insurable interest is void. It means that the insured
must have an actual pecuniary interest and not a mere anxiety or sentimental interest in the subject
matter of the insurance. The insured must be so situated with regard to the thing insured that he
would have benefit by its existence and loss from its destruction. The owner of a ship run a risk of
losing his ship, the charterer of the ship runs a risk of losing his freight and the owner of the cargo
incurs the risk of losing his goods and profit. So, all these persons have something at stake and all
of them have insurable interest. It is the existence of insurable interest in a contract of insurance,
which distinguishes it from a mere watering agreement.

Causa Proxima

The rule of causa proxima means that the cause of the loss must be proximate or immediate and
not remote. If the proximate cause of the loss is a peril insured against, the insured can recover.
When a loss has been brought about by two or more causes, the question arises as to which is the
causa proxima, although the result could not have happened without the remote cause. But if the
loss is brought about by any cause attributable to the misconduct of the insured, the insurer is not
liable.

Risk

In a contract of insurance the insurer undertakes to protect the insured from a specified loss
and the insurer receive a premium for running the risk of such loss. Thus, risk must attach to a
policy.
Mitigation of Loss

In the event of some mishap to the insured property, the insured must take all necessary
steps to mitigate or minimize the loss, just as any prudent person would do in those circumstances.
If he does not do so, the insurer can avoid the payment of loss attributable to his negligence. But it
must be remembered that though the insured is bound to do his best for his insurer, he is, not bound
to do so at the risk of his life.

Subrogation

The doctrine of subrogation is a corollary to the principle of indemnity and applies only to fire
and marine insurance. According to it, when an insured has received full indemnity in respect of his
loss, all rights and remedies which he has against third person will pass on to the insurer and will be
exercised for his benefit until he (the insurer) recoups the amount he has paid under the policy. It
must be clarified here that the insurer's right of subrogation arises only when he has paid for the loss
for which he is liable under the policy and this right extend only to the rights and remedies available
to the insured in respect of the thing to which the contract of insurance relates.

Contribution

Where there are two or more insurance on one risk, the principle of contribution comes into
play. The aim of contribution is to distribute the actual amount of loss among the different insurers
who are liable for the same risk under different policies in respect of the same subject matter. Any
one insurer may pay to the insured the full amount of the loss covered by the policy and then
become entitled to contribution from his co-insurers in proportion to the amount which each has
undertaken to pay in case of loss of the same subject-matter.

In other words, the right of contribution arises when

(I) There are different policies which relate to the same subject-matter
(II) The policies cover the same peril which caused the loss, and
(III) All the policies are in force at the time of the loss, and
(IV) One of the insurers has paid to the insured more than his share of the loss

1.3. TYPES OF MEDICLAIM POLICIES


MEANING: Policies under this insurance, the insurer undertakes to indemnity the assured in
consideration of certain payment, up to certain specified amount insured against for loss
arising in respect of hospitalization or injury sustained by the insured person.

Due to rapid population growth and more and more use of contamination of fond, water, and
air etc., which leads to hospitalization are more frequent. To cater to the varying and
increasing needs, different forms of cover are available.
Types of policies:

The following types of policies are issued by the insurance corporation in order to meet the
public at large:

I. Mediclaim policy (Individual):

Coverage: the policy provides for the hospitalization/domiciliary hospitalization expenses for
illness/diseases or injuries sustained.

Expenses on hospitalization is payable when the insured is admitted in the hospital for a
minimum period of 24 hours. An individual can opt for the sum insured ranging from
Rs.15, 000 to Rs.5, 00,000 in multiples of Rs.5, 000.

Eligibility: People in the between age group of 5 and 80 years are eligible for the policy.
Children between the ages of 3 months to 5 years can be covered provided one or both
parents opt mediclaim over.

Benefits: Reimbursement of hospitalization/domiciliary hospitalization expenses as mentioned


above. Family discount- a discount of 10% in the total premium is available if the policyholder is
opting cover under the policy for any one of the following: spouse, dependent children, and
dependent parents. Cost of health checkups- this cost is payable to the insured at the end of
every four year block provided there is no claim reported during the block. The cost reimburse will
be the amount equal to 1% of the averages sum insured during the block. Premium of Rs.15, 000 is
exempted under income tax section 80D, if paid by cheque.

Conditions: Any event giving rise to claim under the policy should be informed or communicated
to the insurance company in writing within 7 days from the date of injury, hospitalization/
domiciliary hospitalization.

 Claim must be filed within 30 days from the date of discharge from the hospital.
 The company will not be liable for any payment for claim, which are fraudulent or
supported by any fraudulent device.
II. Group medical policy:

The group medical policy will be available to pay or association, institution or corporate
body of more than 50 persons provided it has central administration point. Each insurer
should cover all eligible candidates under one group policy only which means that
different categories of eligible members are not allowed to be covered under different
group Medicalim policies.

The group discount is permissible depending upon the total number of insured person
covered under the group mediclaim policy at the inception of the policy. It is to be noted
that no discount is offered to a group with less than 101 members.

III. Overseas Mediclaim policy:

Overseas Mediclaim policy was originally introduced in 1984 to provide payment of medical
expenses incurred in respect of illness suffered or sustained by Indian resident during their
overseas trips. The insurance scheme, since 1984 has been modified several times to
provide for additional benefits like in-fight personal accident, loss of passport etc. in the
year 1991, employment of study policy was introduced for Indian citizens temporarily
living abroad.

There are two type of plan under overseas mediclaim policy:

 Standard cover.

 Videsh yatra mitra.


Eligibility: the policy is available to the following person:

Indian residents traveling abroad for the following purposes:

 Business
 Official
 Holiday tour
 Professional Training
Accompanying spouse and children of the person going aboard will be treated as going under
holiday travel.

Age limit:

Adults: the age limit is 70 years. Adults between the age of 70 and 80 years can be covered at the
discretion of the insurer by loading the premium and persons above 80, years can also be covered
provided the insurance company's head office accepts the proposal.

Benefits:

The following are the important benefits of overseas medical policy:

 Reimbursements of medical expenses of the insured during his/her stay abroad.


 Automatic extension of insurance period.
 In the event of claim, services will be provided by M/s. Mercury international
assistance and claims limited, whose services are available all over the world.
 If the insured is required to be sent back, to the home country on account of
sickness suffered or injury sustained, the expenses incurred therewith are also paid.
 An amount up to $225 for immediate relief of dental plan is also payable with
the approval of M/s. Mercury.
 All the expenses are reimbursed in the local currency of the country

IV. Jan Arogya Bima Policy:

the coverage under this policy can be considered, to a certain extent, along the lines of individual
mediclaim policy expect that cumulative bonus and mediclaim check up benefits are not
included. The above plan covers the risks or reimbursement in respect of hospitalization and
domiciliary hospitalization up to Rs.5000 per person per annum. The salient feature of the
scheme is granted only for the benefits of the lower income of society and common masses.
V. Cancer policy:

this policy is designed to meet the risks or coverage for the members of the cancer patient aid
association. There are two scheme available for cancer policy:
a. Indian cancer society
b. Cancer Patients Aid Association.
This policy is introduced in collaboration with Indian Cancer Society can avail of the benefits of
this scheme. The policy lapses immediately if the insured ceases to be a member of the
Cancer society for any reason whatsoever. On payment of the prescribed membership fees,
which is included in insurance premium during the currency of the policy suffers from cancer;
the policy will pay up to Rs. 50, 000 to meet the cost of diagnosis, biopsy, chemothera py,
hospitalization and rehabilitation.

VI. Bhavishya Arogya Policy:

This scheme had been designed so as to enable a person to provide himself for medical needs
during an old age security. Under this policy the medical expenses to be incurred over the balance
life span after a predetermined age of retirement will be reimbursed up to the amount of the sum
insured with a limit of an amount per any one illness or injury. The amount of maximum total
benefits available under the basic policy is Rs. 50, 000 during the lifetime of the insured
commencing from the policy retirement age and is not to exceed Rs. 20, 000.

VII. Videsh Yatra Mitra Policy:

Videsh yatra policy is another overseas mediclaim scheme introduced by general Insurance
Corporation with effect from 1998. This policy provides the widest cover of personal accident, loss
of checked baggage, loss of passport, medical expenses and repatriation, delay of checked baggage,
personal liability etc. insured person is that person named in the overseas policy schedule, for which
the appropriate premium had been paid. The policy is valued only from the first day of insurance
and expires on the last day of the number of days specified in the policy schedule or on return to
India whichever is earlier.

1.4. HOW TO CHOOSE A MEDICLAIM POLICY

Mediclaim policy is intended to provide coverage to unexpected medical expenses that may lead to
financial hardships. With growing popularity of the health insurance policy, it becomes nearly
impossible for us to pick out a suitable policy at the affordable prices. Like all other forms of
insurance, medical health insurance also comes with different policies and premium rates. A
government organization or private insurance companies may provide medical health insurance.
However, here are some tips and tricks shared with you, so that you can have no problem while
choosing the mediclaim policy for your needs.
First, we should discuss that most of the mediclaim policies come with a minimum duration of 1
year and a maximum duration of 2 years. It is framed by evaluating the overall healthcare expenses
and the monthly premium to be paid. These details are included in the insurance agreement and
accordingly the benefits are paid by the insurance company. You can buy the mediclaim policy
collectively or individually. Collective policies may include family insurance, group insurance or
short-term health insurance. Family mediclaim policies include the entire family that is stay-at-
home parents; students etc. while the Group insurance are usually bought by employers to cover all
their employees at discount rates and greater benefits. However, in both the cases, the amount of
premium is nominal.

Short term insurance offers coverage for short span of time like college years or in between jobs etc.
Such kind of mediclaim policy usually preferred by self employed, entrepreneurs etc. At a low rate,
an individual can opt to cover his or her spouse as well. This is flexible with a wide range of rates
and premiums. Opting for the right scheme or policy may save you from incurring heavy expenses
that may crop up from an unforeseen accident or hospitalization of the loved one.
There are many mediclaim policies, which cover a certain set of accidents and ailments. Any pre
existing ailment like diabetes, poor eyesight etc is not included in the insurance. In this case, the
insurance provider covers the hospitalization bills after a brief check whether the rates applied are
in line with the agreement made. However, any cost other than the rates applied by the insurance
company is to be carried out by the patient himself. Surgical costs, outpatient bills are covered only
if the amount fits the amount quoted in the insurance agreement.
Mostly, the mediclaim providers have a list of network hospitals, which provide a discount or other
benefits to the client if the treatment is taken from any one of the hospitals enlisted. The interesting
fact is that, nowadays many insurance providers offer provide cover to homeopathic treatments,
however, in that case, you gave to get treatments from certain specified hospitals. Such mediclaim
policies also offer coverage for death of the person covered and the benefit amount would be
received by the nomine.
Choose a policy, which is easily customizable and offers you the reimbursement at the earliest.

MEDICLAIM FOR EMPLOYEES


The employers generally buy Mediclaim for the employees from the insurance provider in order to
offer a large number of benefits to their employees. Employers mainly consider on offering his
employees something necessary and important and in their list of benefits, mediclaim is considered
as the most essential and important benefits available from the employers. Nowadays, mediclaim
has become an important part of the health insurance and since the cost of the medical emergencies
are soaring high day by day, the mediclaim policy has become all the more necessary. The
employers offer various kinds health and medical benefits to their employees in the form of group
medical cover or the mediclaim cover for employees.

Group mediclaim policy or the mediclaim policy for a group of employee covers reimbursement of
hospitalization expenses incurred for sickness, diseases and accidental injuries. Apart from these,
such mediclaim policies also offers comprehensive coverage to pre and post hospitalization
expenses up to 30 days prior and 60 days after hospitalization. Additional benefits such as maternity
cover can be added with basic policy on payment of extra premium. However, the area of coverage
encompassed by the mediclaim policy differs from one company to another.
However, there is a misconception that the group mediclaim or the mediclaim policies intended for
the employees is not enough for health care needs, it does not provide comprehensive coverage to
all healthcare needs but it is equally true that the required coverage is always available under this
policy. If you want to be protected from both sides, the best and smart decision will be to opt for
both the individual as well as the group mediclaim policy. While one cover you from the required
amount of expenses, the other will offer coverage for those which has not been provided by the
former. This is affordable because for employee mediclaim you do not need to carry out the
expenses of the premium, because that will be paid by your employer.
Group Mediclaim policy comes with a huge discount depending on the size of the group. As large
as the group size will, the higher will be the discount is available.
Mostly, the group Mediclaim policies are offered by corporate body, institutions, association or any
homogeneous groups. The minimum coverage is Rs.15, 000/- and the maximum is Rs.5, 00,000/-.
The premium of the mediclaim policies depends upon the age of the employee and sum insured.
The age limit of the group mediclaim policy or the mediclaim policy for the employee is 5 years to
80 years and children above 3 months can be covered, if one or both parents are covered
concurrently.
Today, there are various insurance companies are providing group plans. Check out and gather as
many information about the coverage and premium cost. Ask directly to the employer if necessary,
for such details. Sometimes the insurance companies ask to pay higher premiums to their customers
after issuing policies. Hence, it is highly recommended to make a thorough research before you sign
the contract.

INDIVIDUAL MEDICLAIM POLICY


Mediclaim is a kind of insurance policy that offers coverage to unexpected medical emergencies,
which may end up with financial hardships. With the growing necessity of Mediclaim, Health
insurance has emerged as one of the leading contributing sector to India’s economy. A government
organization or private insurance companies offer medical health insurance, which is popularly
known as Mediclaim.
Individual Mediclaim policy comes with a minimum duration of 1 year and the customer can only
get it extended for a maximum duration of 2 years. Health insurance providers usually frame a
detailed financial structure, on the basis of the estimation of overall healthcare expenses and the
monthly premium to be paid. Such details are mentioned in the insurance agreement and the
insurance company pays the benefits.]

Individual mediclaim policy is usually designed for the self employed, and small entrepreneurs, in
which the covers of the medical expenses is available only to single person. Such mediclaim
policies are available at a low rate, and the individual can opt to cover his or her spouse in that
mediclaim policy as well. Individual medical insurance is highly flexible with the varied range of
rates and premiums available for people from different profession. If you successfully opt for the
right scheme or policy, it may save you from unexpected financial disaster due to heavy expenses
stemming from an unforeseen accident or hospitalization of the loved one.
However, you should ponder on the fact that individual mediclaim policy pays for only a certain set
of accidents and ailments. Any chronic ailment like diabetes, poor eyesight etc is not encompassed
by this policy. You can also get coverage for the hospitalization bills but these are only covered
after the insurance company perform verification whether the rates applied commensurate with the
normal amount charged by other hospitals in the area. Any extravagant costs have to be borne by
the patient. Surgical costs, outpatient bills are covered, in case the amount fits to what quoted in the
insurance agreement. Expenses beyond the authorized amount will have to be carried out by the
patient.
Medical insurance companies usually select a list of hospitals and make a contract with them,
according to which the hospital provide a discount or other benefits to the client if he is admitted in
any of the network hospitals. However, it is not mandatory to opt for these hospitals. Nowadays,
some insurance companies also provide insurance coverage to homeopathic treatments, if the
patient is admitted in certain specified hospitals. In many cases, after the death of the insurance
policy holder, the nominee will receive the benefit amount of the policy.
Individual mediclaim policy, which comes with a low premium rate and covers a majority of
ailments and accidents, is considered as the best policy. Check out first and then opt for the policy,
which pays at the earliest in case of an emergency. Many a times, a patient has to reimburse the
amount, but make sure that the process is hassle free from all aspects.

HEALTH INSURANCE POLICY FOR RETIRED PENSIONERS


If you are nearing retirement and having exasperating thoughts about post retirement money
management, here is a solution for you. There are many, who are mostly worries about the
healthcare. Since healthcare, in recent years can dip your pockets deep, it is very natural to worry
about it, when there will not be the regular supply of money after retirement. Therefore, the best
idea is to make retirement plans and to invest in getting a health insurance policy. Before, you buy a
health insurance policy, it’s better to collect some information about that.

Health insurance policy in India is available from the Government as well as from the private
insurance providers. Most of these policies are available to people aged 65 years or older and main
source of income is the post-retirement pension. Certain disabled individuals are also entitled to
have the policy if they are retired pensioners.
The health insurance policy available for the retired pensioners offers different kind of coverage
depending on your requirements. However, the basic medical expenses are offered by all of the. It
does not typically pay the total cost of covered services or supplies but can pat a large amount to
support you with your needs.
Mostly you can have four types of coverage.
The first type can help you pay for inpatient hospital care, skilled nursing facilities, hospice care,
and some home health care. The best part of such type is that, a retired pensioner would not need to
pay the monthly premium for it. You need to pay the premium, if you are working after 65 years of
age.
The second type of insurance coverage helps in offering coverage to doctors’ services, outpatient
hospital care, physical and occupational therapy and some home health care. Such insurance
policies usually charge a payment of a nominal monthly premium. This type of insurance coverage
can be customized depending on your requirement, and the premium depends according to the
customization of the insurance coverage.
The third type of healthcare insurance policy includes coverage for drugs and meducation. You can
also avail the plans, which cover medical and healthcare necessary services. However, plan can
charge different co-payments, coinsurance, or deductibles for these services.
The fourth type of insurance plan provides coverage for prescription drug benefits. The prescription
drug plans will generally require you to pay a monthly premium and co-payment or co-insurance
for each prescription you fill. Plans vary by cost, number of drugs covered and pharmacies you can
use, however, there is a standard amount of available coverage under this plan, which will be set by
the insurance provider. Such kinds of drug plans work with all types of medical and health care
plans including the Original Medicare Plan, Private Fee-for-Service Plans, and many other Plans
(like HMOs).
In order to avail any of these healthcare benefits, you have to talk to the agents of the insurance
providing firm. He can help you framing your healthcare plans and after retirement and can offer
you advices for selecting the right policy and any customization required.

GROUP INSURANCE
Group insurance refers to a special kind of health care insurance plan in which individual
employees or a group of employee is covered under one ‘master policy’. The employer purchases
such kind of group insurance for his employees. The best part of the group insurance plan is that, it
has so many contributors and as a result, it offers coverage for more than one service at a much
lower cost of premium. Apart from the “from-profit” organizations, non-profit organization, labor
unions, churches and other service groups can also get group insurance policy in order to make their
employees covered from any sort of unforeseen health hazards, which may incur heavy expenses.

Each member under the group insurance scheme receives insurance certificates, which demonstrate
their eligibility for receiving benefits. In this case, often the employer, who has to be a part of an
HMO (health maintenance organization), holds the master policy. Similarly, the individuals (his
employees) are also registered as members of the organization. There are many group insurance
policies, which are associated with major medical groups such as Blue Cross or Blue Shield.
According to the terms and conditions, laid by a medical policy, it may or may not restrict an
individual’s choice of primary physician and specialists. However, HMO policies are a bit different,
which often require a patient to use a specified physician, who is entitled to approve any visits to
any eligible specialists, if required.
When it comes to financing for a group insurance policy, it is a flexible payroll deduction.
However, there are some companies, which will bear the total cost of the policy as a benefit for
employees. But, the problem crops up with many insurance policies, when their cost of premiums
rise up significantly without any prior notification or warning. The problem is that, if a few
participants of the group receive expensive treatments for serious medical conditions, the rest
members of the group, has to bear the higher premium costs over time, although they are not having
such treatments. To enjoy the benefits of group insurance policy, the insurance providers will ask
for the physical exams before issuing a master policy. The most beneficial part of such physical
tests is that, participants, having serious illness can be covered from treatments for pre-existing
conditions.
Group insurance benefits can vary widely from company to company. Typically, most of the
policies cover basic emergency and routine medical procedures such as regular doctor’s
appointments and hospital treatment for accidents. The difference between the coverage is made
when any plan offers extended care in hospitals or rehabilitation centers.
Group insurance may or may not cover the employee’s spouse or dependents, while some policy
plans offer assistance for vision care or dental work; but in this case, the policy coverage will be
limited to specific procedures. Some policies also cover mental health needs under group insurance.
Prescription drug expenses fall under group insurance benefits, but it will come with a co-pay
provision. Under a co-pay plan, the individual enjoying the policy should be entitled to pay an
established price for name brand and generic medications.
CASHLESS MEDICLAIM POLICY FOR FAMILY
Cashless Mediclaim policies nowadays are available for the entire family. It offers comprehensive
medical coverage to all the family members under the same policy. Generally, the term family
implies one self, one’s spouse and dependent children. Dependent children refer to those kids who
are dependent on their parents’ income.
The age of these dependent children can differ from policy to policy as different insurance provider
may have different age criteria for dependent children. However, the general rule says that the
dependent children will vary from the age group of 21 or 25. It is highly recommended to clarify
this point before applying for the cashless Mediclaim policy for your family. Generally, in the case
of family insurance the parents are not covered. The family Mediclaim policy is not different from
other Mediclaim policy. To buy any policy, the most important responsibility is to go through terms
and conditions of the Mediclaim policy in detail so that you can understand clearly what all is
covered under the family insurance plan.

Although, the cashless Mediclaim policies for the families may differ from company to company,
yet it is true that most of them will cover any medical expenses that are incurred during the time in
which the patient being hospitalized or injured. The premiums of the cashless family mediclaim
policy are also different according to the terms and conditions laid by the company. Therefore, it is
imperative for you to go carefully through every clause of the cashless policy, before you sign it
and get your entire family covered under it. No matter how affordable is your insurance policy, you
need to stay abreast of all its terms and conditions. The family Mediclaim policy will thus bear any
medical cost that may be incurred due to the treatment of any member of your family who is
covered under the policy.
In recent years, mediclaim is a must for every individual. However, you can save money by opting
for a family mediclaim policy instead of buying an individual mediclaim policy. Covering the entire
family members under a single policy for a single sum is affordable and saves both time and
money.
For your parents, you can avail cashless mediclaim policy up to the age of 60 years. If your gamily
Mediclaim policy does not offer you the same, you can opt for a senior citizen mediclaim policy.
Opting for the latter will give your parents the comprehensive coverage.
The premium of the cashless Mediclaim for family depends upon the various factors such as age of
the person, size of the family and coverage offered under the policy. The premium cost also varies
from company to company.
You will find a wide assortment of family mediclaim policies in the market that covers your entire
family members. Offering a variety of benefits to ensure your family members, these policies are
not too different from each other. Cashless Mediclaim policies for families, encompasses the cost of
in-patient hospitalization treatment, pre hospitalization, post hospitalization, domiciliary
hospitalization, day care procedures, ambulance charges, etc. Some of them are also available for
critical illness.

ONLINE MEDICLAIM POLICY


Online mediclaim policy is a special kind of health Insurance coverage, which allows you to claim
any of your health related hospitalization bills from the insurance provider via internet. Under the
coverage of the online mediclaim policy, you can make your claims by two processes: first, by
cashless facility i.e your bills are directly paid to the hospital and the second process is that, you can
pay your bills in the hospital and get an reimbursement only after the submission of the actual bill
and other details to the insurance provider. While a mediclaim policy can save financial loss in case
of hospitalization for any unforeseen medical emergency, sickness, disease or accident, doing it
online can save a great deal of manual labor.

In the recent years, when the, medical expenses are higher than any other expenses. It becomes even
more appalling, when you will find that such expenses are increasing at a rapid scale. The latest
family mediclaim insurance is ideal solution to get over such tensions and at the same time, it will
help you to pay your bill. Since all the members of the family can come under the same policy, you
do not need to bear multiple premiums and hence no more financial strain. A mediclaim or a health
insurance policy also provides for reimbursement of hospitalization. Moreover, if an individual is
bed ridden and needs an attendant or a nurse, he can cover the expenses easily with a mediclaim
policy and you do not need to go to the insurer if you have the access of internet at your home.
Expenses associated with treatments such as dialysis, chemotherapy, radiotherapy etc are also
covered by the mediclaim policy. With online facility, you can pay the hospital bill even when you
are taken hospital or a nursing home and then discharged on the same day. Such kind of treatment
will be considered to be taken under ‘Hospitalization Benefit Scheme’ of online mediclaim policy.
This policy is available in two variants – short term and long term and the coverage level, which is
somewhat similar like other traditional mediclaim policies. Apart from providing covers for
hospitalization expenses for illness and diseases, it also encompass the expenses for doctors fees,
nursing expenses, medicines, blood, surgical appliances and other related expenses.
While applying for online mediclaim policy, you have to make sure that the coverage provided by
the insurance provider is comprehensive enough. Any disease or sickness existing before the
mediclaim is taken will not be covered. Each mediclaim policy has its own and unique list of
specific exclusions. Check the list carefully before signing the contract paper. Most of the Insurance
Companies do not offer mediclaim for obesity related illnesses, expenses arising from HIV or AIDS
or the use of alcohol or drugs and expenses due to attempted suicide. The most basic expenses
include the treatment due to war, riots or a terrorist attack is not insured by policies.
However, it is always advisable to talk to the financial advisor before applying for any policy.

MATURING INSURANCE POLICY


Perhaps getting an insurance policy is the best possible way to protect yourself from unexpected
financial strain, which may crop up at any phase of your life. A lot of people across the world are
relying on different kinds of insurance policy is order to evade heavy financial losses. However,
many of them are facing challenges, when they do not get the coverage amount properly. The
obvious reason is that, they do not have a proper idea about a mature policy and an immature
policy. You may not get the most out of your life insurance policy if you do not let it get matured.
Therefore, a clear understanding of both the matured and immature policy has to be understood
before starting financial planning.

A mature insurance policy refers to a policy, which offers guaranteed cash value of the policy and
that amount equals to the total face value of the policy. The cash value is gained from the premiums
you pay on monthly basis. The rule of thumb is, the longer you pay your premiums, the closer you
will get to having a mature policy. The mature insurance policies refer to the types of life insurance
policies (e.g., whole, universal), however, the term life insurance policies are not included in it.
Policies usually are set to mature, or endow, when the policyholder reaches age 100. However,
maturing policies depend on the kind of policy you have chosen. However, the date of maturity
depends on the face value of the property and the premium you pay.
Your policy matured at the time when you have paid every premium within a schedules date or age
specified in the policy. After, your policy gets matured, the insurance company should pay you both
the face value and cash value of the policy. In case you are alive when the policy matures, you can
enjoy the benefit of the insurance company bearing all your expenses till you die. Moreover, you do
not need to make premium payments once the policy is matured and the insurance company has
issued you a check.
Very often, the insurance companies do not notify you when your insurance is about to mature. The
reason is that the policy effectively terminates, when the insurance company pays you the value of
the policy. Therefore, you are likely to stop paying premiums, which are the main source of income
of the insurance provider. You can also continue insurance coverage after the insurance company
pays you; however, in that case, you have to get a new policy.
If your life insurance policy matures on your 100 years of age and you do not want to wait till then,
you can also take out your policy before it matures. Many people surrender their policies for the
cash value. However, the insurance company pays out a benefit when the policyholder dies, if the
policy did not mature by his lifetime. It is needless to say that a mature policy has more cash value,
and you will get less from your policy if you cash it before maturity.

MEDICLAIM PORTABILITY
With the introduction of Mediclaim portability all over India, the Medical policyholders with IRDA
or those who are enjoying the facility of Mediclaim can use the insurance policy with due
convenience. The mediclaim portability will help the customer by providing the opportunity to find
an insurance carrier, which, can appropriately commensurate with their needs and lifestyle. The best
part of this mediclaim facility is that if a policyholder is not satisfied with his or her current
provider, he or she can have the facility to switch to another health insurer or provider without any
change in the premium outgo.

The convenience of Mediclaim portability will be available to policyholders who are currently
insured for a sum of 1, 00, 000 and above. According to the present rule, the health cover given to
any policyholder, under the plan of medical portability has to be renewed every year. In case, there
is no claim in any year, the policyholder is entitled to a bonus in the form of an increased sum and
for every claim-free year, this bonus gets accumulated.
The industry and the regulators are working on the minimum benefit that would be carried forward
in case of change in the insurance provider, as two insurers do not generally have the same
mediclaim policies. The regulator is also considering portability for car insurance or home
insurance.
There are several benefits, which mediclaim portability can offer you. With overwhelming number
of benefits, the policyholders can compare different policies provided by various insurance
providers. The chief expenses, on which you can compare your policy are hospitalization expenses,
day-care procedures, effects of cumulative bonus and various types of illnesses covered under
critical illness domain.
Apart from the service factor, policyholders can also compare insurance providers on the basis of
the denial of their policy renewal and the increasing costs of their renewal premiums. However, it
can be said, that such kind of Mediclaim portability will be most useful for the people aged 65 or
more. Most of the senior citizens currently having serious problems in changing insurance
providers, primarily because the new insurance providers consider the policy as completely new
one, and the diseases and accidents, which might have been covered by the previous company, are
treated as pre-existing.
With mediclaim portability, the policyholder can now switch their insurance provider if they are
getting rude replies from their executives and are not satisfied with any of their services without any
change in the premium.
In a country like India where medical insurance policyholders is merely 6-7%, the new mediclaim
portability, when put into practice by the insurance regulator, can give the industry a nudge. The
new mediclaim portability is more competitive and it is expected to offer customer friendly service
to the policyholders.
However, before opting for mediclaim portability it is always advisable to consult with the
insurance agent. He will help you to pick out a proper policy for yourself and if required he will
help you to get the policy customized.

1.5. HOW TO FILE A CLAIM AFTER HOSPITALIZATION


Mediclaim is one of the best ways to relieve the stress of acquiring money during the situations of
medical emergencies. It becomes easier now after the introduction of the cashless mediclaim policy.
However, filing a claim after hospitalization requires several considerations and in this article, we
are going to share all those process, which are essential to file a claim after hospitalization.
A Mediclaim can be filed in the following situations:
1. Emergency hospitalization
2. Planned hospitalization

Emergency Hospitalization
During the situation of emergency hospitalization, in case the insured person is admitted in any of
the network hospitals of the insurance provider, the hospital will ask for the compensation to the
insurance provider as per the rules set by the network hospital and the insurance provider. They will
then contact the TPA and send a request for authorization. The insurance provider may or may not
approve the claim, however, it is based on the terms and conditions of the contract signed by the
hospital and the TPA. Generally, the time taken to process an emergency case is 6 hours. It is the
responsibility of the customer to follow up with the TPA in order to be informed about the status of
your request. In case you have bought your policy through a specialized health insurance advisor or
agent or a broker, they will provide you the required assistance in coordinating the claim from the
insurance provider.

Planned hospitalization:
During the situation of emergency hospitalization, in case the insured person is admitted in any of
the network hospitals of the insurance provider, the hospital will ask for the compensation to the
insurance provider as per the rules set by the network hospital and the insurance provider. They will
then contact the TPA and send a request for authorization. The insurance provider may or may not
approve the claim, however, it is based on the terms and conditions of the contract signed by the
hospital and the TPA. Generally, the time taken to process an emergency case is 6 hours. It is the
responsibility of the customer to follow up with the TPA in order to be informed about the status of
your request. In case you have bought your policy through a specialized health insurance advisor or
agent or a broker, they will provide you the required assistance in coordinating the claim from the
insurance provider.
In most cases, planned hospitalization is the result of the recommendation from a doctor that you
would need to be hospitalized. In such cases, you will have the time to decide, where you will get
admitted. The insurance provider will provide you a list of network hospitals available with the
TPA, from which you can select the one of your choice. It is recommended that you complete the
cashless service formalities at least 3-4 days before you are hospitalized. To file the claim, you gave
to follow the given rules here.
 Firstly, you have to complete the pre authorization form, which is available from the
insurance desk of the hospital, or you can download it from the website of your TPA.
 Being a patient you have to fill the form accordingly. A part of the form will need to be
filled by the doctor, who recommended your hospitalization.
 The pre authorization form should be submitted at the insurance desk of the hospital. After
the submission, the form will be verified by the representative at the insurance desk of the
hospital and then fax it to the TPA.
 After verification, the TPA will process the form further but the insurance provider can
either accept it or reject the request.
 You will have to follow up with the TPA to stay abreast of the status of your requests.
 If the insurance provider does not approve the amount send by the hospital, the individual
has to pay the amount to make up the difference.

1.6. FEATURES OF MEDICLAIM POLICY

 Can be renewed annually. Some insurers offer renewals every 2 or 3 years


 Can be opted for Individual or Family Floater
 For anyone between the age of 91 days to 65 years
 Covered pre-existing medical conditions after a waiting period of 3-5 years
 Can be bought online without any paperwork
 Sum insured opted can be as much as Rs. 50 lakhs
 Can be ported to different insurer at the time of renewal
 Gives you a complete health cover and protects your savings.
 Get higher cover at affordable premiums.
 It is the most pocket-friendly means for adequate medical assistance.*
 Cashless hospitalisation ensures you don't have any out-of-pocket medical expenses.
 Easy online buying process from the comfort of your home.
 Get tax deductions on premiums paid under Section 80D of the Income Tax Act, 1961.

MEDICLAIM POLICY - SALIENT FEATURES


1. The Health Insurance Scheme is a stand-alone scheme for inpatient (IP) cashless treatments
of FACT employees and dependents (The Scheme is de-linked from Company’s CHS -
Contributory Health Scheme) and was introduced in the year 2010.
2. The Scheme provides a family floater of Rs.1 lakh with a Corporate buffer of Rs.50 lakhs.
3. Definition of family includes dependent spouse, children and parents. There shall be no
restriction on the number of dependents to be covered in a family.
4. The Scheme covers existing illness of the members.
5. The members are free to avail treatment in any hospital including private consultation.
6. Ayurveda and homeopathy treatment are not included in the Health Insurance Scheme.
7. Pre-hospitalisation and post-hospitalisation period is 30 days each and that will be part of IP
treatment procedure.
8. Ceiling on room rent (including charges for utilities) is Rs. 500/- per day and ICU charges is
limited to Rs.1000/- per day.

9. 24 hours Hospitalisation is not necessary for treatments like:


a) Haemo Dialysis,
b) parentral Chemotherapy,
c) Radiotherapy,
d) Eye Surgery,
e) Lithotripsy (kidney stone removal) etc etc. (The exhaustive list included in the
Policy/Agreement).
10. The Critical illness include heart diseases, stroke, kidney failure, cancer, angioplasty,
cerebral haemorrhage and burns above 30%.
11. Maternity cases will continue to be covered as per CHS Rules.
12. Corporate buffer will be used when an employee has exhausted his family floater of Rs.1
lakh. 13. For dependent parents there will be a limit of Rs.1 lakh for Critical illness and
Rs.50,000/- for non-critical illness for each parent.
13. The employees who retire during the validity of the Health Insurance Scheme will continue
to be covered under the proposed Insurance Scheme.
14. The employees can continue to avail Mediclaim Policy from the insurance company after
retirement by paying the required premium.
15. In the event of utilising fully the Corporate buffer, subsequent claims will be reimbursed as
per existing CHS rates.
16. For treatments like AIDS, alcohol induced lever diseases etc which are not included in the
Mediclaim Policy, reimbursement would be considered as per CHS Rules.
17. If there happens to be increase in man-power, pro-rata premium will apply.

1.7. BENEFITS OF MEDICLAIM INSURANCE

Benefits of a Mediclaim policy are many. Some of which are listed below.

1) First and foremost the Mediclaim policy offers you a chance to get your medical expenses
covered under a policy. Thus it takes care of the hospitalization fees. Protects the person or family
(in case of family plan) for hospitalization expenses as a result of any specific injury or illness
which has taken place during the period of insurance and on the advice of a doctor requires
hospitalization.

2) Pre hospitalization expenses for the person or the insurer and also to go with it Post-
Hospitalization Expenses: Post Hospitalization expenses are medical expenses incurred during a
period up to a specific number of days after hospitalization for the particular ailment disease or
injury is over but still needs expenditures in order to completely become normal.

3) If you have a health insurance policy that supports cashless Mediclaim, it means that you can get
medical treatment just by displaying your insurance card without paying any cash to the hospital.
Most health insurance companies offer this benefit. Some times the benefits may be applicable only
to a certain number of hospitals or medical centers.

4) Some of the insurance policies also provide tax benefits. These tax benefits are provided to the
person under the name of whom the insurance policy has been assigned. Under the Section 80D, tax
benefits are provided to people who get a Mediclaim policy done in their n
1.8. DATABASE OF MEDICLAIM INSURANCE
General Insurance Corporation through its four subsidiaries: Oriental Insurance, New India
Assurance, National Insurance Company, United India Insurance.

Age:
Between 5 - 80 years.

Children between 3 months and 5 years can be covered provided one or both parents are also
covered.

Coverage:
Insures against any hospitalization expenses that may arise in future. The scheme reimburses
hospitalization expenses for illness, diseases or injury sustained, excludes any disease existing
before taking the policy.

Cost:
Sum insured can be anywhere between Rs 15,000 - Rs 500,000. Rate of premium ranges between
Rs 175 per year to Rs 2,500 per year depending on the age and capital sum insured.

Amount:
Compensation up to the extent of sum insured.

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