Health (Mediclaim) Insurance Policy - Coverage & Exclusions
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devarajan shanmugam
Jul 9, 2009, 11:40:12 PM7/9/09
to MediclaimPolicyforAll
Health (Mediclaim) Insurance Policy - Coverage & Exclusions
Before buying a health insurance policy (popularly known as mediclaim
policy), you should be aware of some basic features like what does the
health (or mediclaim) policy cover and what it does not cover? This
post tries to provide you a brief but comprehensive overview of the
basic features of the coverage provided by various health / mediclaim
insurance policies available in India as of now.
Coverage: Restrictions & Limitations
1. Maximum Cover
Most insurers have put a maximum cap of Rs 5 lakh on the sum insured
except for a few insurance companies such as Star Health and Allied,
Apollo DKV, Bajaj Allianz, Cholamandalam MS General Insurance, United
Insurance company and which provide coverage up to Rs ten lakh.
2. Sub-limits
Now-a-days, most mediclaim policies come with sub-limits on various
expenses like room rent, doctor’s fees, diagnostics etc. For instance,
National Insurance Company (NIC) under its Mediclaim Insurance Policy
(Individual) has imposed room rent limit of 1 per cent of sum insured
per day subject to a maximum of Rs 5000; however, if admitted in ICU
the room rent limit is two per cent per day and maximum limit becomes
Rs 10,000. Furthermore, the mediclaim policy of NIC also stipulates
that total of room, boarding and nursing expenses can’t exceed twenty
five per cent (25%) of the sum insured per illness.In Star Health
Insurance room rent and boarding 2% of sum insured subject tp a
maximum o Rs. 4000 a day.
What are its implications? Put simply, you’re not allowed to claim
more than the stipulated amount under any specific head. It also means
that you may have to foot the medical bill partly even if the total
bill is below the sum insured. For Instance, if your health policy sum
insured is Rupees two lakh, room rent expenses will be allowed only to
the extent of Rs 2,000 per day (in the above mentioned mediclaim
policy of NIC). Any room rent expenses beyond this would have to be
borne by you.
3. Hospitalisation
Usually a minimum hospitalization of 24 hrs is required for filing a
claim under mediclaim policies.
However, for certain medical treatments (Day Care Treatments) and
minor surgeries the limit of 24 hrs hospitalization is waived off. For
example, Apollo DKV Easy Health policy covers medical expenses for 140
day care procedures which do not require 24 hours hospitalisation due
to technological advancements.
A few such treatments are listed below:
a. eye surgery
b. dental surgery due to accident
c. dialysis
d. Coronary angioplasty and angiography
e. Kidney stone removal
f. Treatment of fractures / dislocations excluding hairline fractures
g. Surgery of Appendix, Gall Bladder, Pancreas, Bile Duct, Hernia,
Prostate and ENT
h. Radiotherapy.
4. Pre & Post Hospitalisation cover
Besides hospitalization expenses, most healthcare policies also allow
you to claim relevant medical expenses incurred during 30 days prior
to hospitalization and 60 days after hospitalization.A few healthcare
policies provide wider coverage like Chola Health Insurance Plan
covers 60 days prior to hospitalization and 90 days after
hospitalization if you inform them well in advance.In star Health
Insurance for post hospitalisation, a lumpsum calculated at 7% of the
hospitalisation (excluding room charges)subject to a maximum of Rs.
5000/ is payable.
5. Domiciliary Hospitalization
Domiciliary hospitalization means the medical treatment is done at
home for a period exceeding 3 days for any ailment or injury, which
otherwise would require hospitalisation, due to either non-
availability of accommodation in the hospital / Nursing Home or if the
condition of the patient is such that he cannot be moved to a
hospital.
Only a very few insurance companies allow domiciliary
hospitalization. For instance, while Reliance Health Care Policy and
Apollo DKV Easy Health policy allows domiciliary hospitalisation,
Bajaj Allianz, ICICI Lombard and National Insurance Company exclude it
from the coverage.
Exclusions
It is always better to know beforehand various exclusions and
limitations about the mediclaim policies so that you’re aware of the
exact scope of the policy coverage to avoid the disappointment later
at the time of making a claim. Some of the common exclusions (although
vary from policy to policy) are as follows:
6. Waiting Period
Almost all Healthcare or Mediclaim policies carry a waiting period
usually of 30 days. Put simply, you can’t make any claim for any
diseases contracted within 30 days of buying the health / mediclaim
insurance. However, accidental injuries are covered from day one i.e.,
waiting period is not applicable in case of hospitalization / surgery
due to accident.
7. Pre-existing diseases
A fresh mediclaim policy doesn’t cover pre-existing diseases. They get
covered only if you don’t make any claim for 4 or 5 consecutive years.
In other words, pre-existing diseases gets covered usually after 4 or
5 continuous claim free years.
For example, while National Mediclaim policy, United India Mediclaim,
Star Health Insurance, Apollo DKV Insure Health and Bajaj Allianz
Health Guard cover pre-existing diseases after 4 claim free years,
Royal Sundaram Alliance Health Shield Standard, ICICI Lombard
Comprehensive Health and Bajaj Allianz Insta Insure cover them after 5
claim free years.
However, there are exceptions also, for example Reliance Individual
Mediclaim (silver plan) and ICICI Lombard Health Advantage Plus covers
pre-existing diseases after second year (i.e., from third year
onwards), and Apollo DKV Easy Health covers them after a period of 3
years.
8. Temporary Exclusions
There are certain diseases which are covered after 1 or 2 years.
For example, Medi-Classic Individual Policy from Star Health and
Allied Insurance Company Limited excludes Hysterectomy, replacement
surgery for knee and / or joint ( other than caused by accident),
prolapse of interverbial disc(other than caused by accident), varicose
veins and varicose ulcers. during first two years. Benign prostate
hypertrophy,Hydrocele, Hernia, Piles,fistula in anus, Sinusitis, Gall
stone and Renal Stone removal / treatment etc during the first year
In contrast, Mediclaim Insurance Policy from NIC excludes (in addition
to other temporary exclusions) all the above ailments (except Joint
replacement surgery) during first two years. Besides, it excludes
Joint replacement due to degenerative conditions, age related
osteoarthritis and osteoporosis during first 4 years of policy.
Similarly ICICI Lombard Health Advantage Plus also excludes (in
addition to other temporary exclusions) all the above mentioned
medical conditions or treatments during first two years.
9. Permanent Exclusions
There is a long list of ailments that are excluded from the purview of
mediclaim policies. Here’s a list of few such general ailments and
medical treatments which are not covered:
a. Dental treatment except arising out of accidents.
b. Pregnancy and child births
c. OPD expenses
d. Naturopathy, alternative medicine/treatments including acupressure
and magneto-therapy etc.
e. Sexually transmitted diseases (STD) and AIDS
f. All psychiatric disorders
g. Circumcision, cosmetic surgery, plastic surgery unless required to
This is only an indicative list. Further, there are many exceptions to
the above list, for example, Medi-Classic Individual Policy from Star
Health and Allied Insurance Company Limited allows for treatment under
alternative system of medicines (except Naturopathy treatment) but is
limited to 25% of the sum Insured, subject to a maximum of Rs 25,000
in the entire policy period.
Similarly, ICICI Lombard Health Advantage Plus ,Apollo Dkv, Star
Health Gain also allows OPD expenses, dental treatment etc (but
subject to limits specified).
10. Overseas Medical treatment
Medical treatment abroad is also not covered under the health /
mediclaim policies
We have to take overseas Travel mediclaim policies before departure.
Before buying a health insurance policy (popularly known as mediclaim
policy), you should be aware of some basic features like what does the
health (or mediclaim) policy cover and what it does not cover? This
post tries to provide you a brief but comprehensive overview of the
basic features of the coverage provided by various health / mediclaim
insurance policies available in India as of now.
Coverage: Restrictions & Limitations
1. Maximum Cover
Most insurers have put a maximum cap of Rs 5 lakh on the sum insured
except for a few insurance companies such as Star Health and Allied,
Apollo DKV, Bajaj Allianz, Cholamandalam MS General Insurance, United
Insurance company and which provide coverage up to Rs ten lakh.
2. Sub-limits
Now-a-days, most mediclaim policies come with sub-limits on various
expenses like room rent, doctor’s fees, diagnostics etc. For instance,
National Insurance Company (NIC) under its Mediclaim Insurance Policy
(Individual) has imposed room rent limit of 1 per cent of sum insured
per day subject to a maximum of Rs 5000; however, if admitted in ICU
the room rent limit is two per cent per day and maximum limit becomes
Rs 10,000. Furthermore, the mediclaim policy of NIC also stipulates
that total of room, boarding and nursing expenses can’t exceed twenty
five per cent (25%) of the sum insured per illness.In Star Health
Insurance room rent and boarding 2% of sum insured subject tp a
maximum o Rs. 4000 a day.
What are its implications? Put simply, you’re not allowed to claim
more than the stipulated amount under any specific head. It also means
that you may have to foot the medical bill partly even if the total
bill is below the sum insured. For Instance, if your health policy sum
insured is Rupees two lakh, room rent expenses will be allowed only to
the extent of Rs 2,000 per day (in the above mentioned mediclaim
policy of NIC). Any room rent expenses beyond this would have to be
borne by you.
3. Hospitalisation
Usually a minimum hospitalization of 24 hrs is required for filing a
claim under mediclaim policies.
However, for certain medical treatments (Day Care Treatments) and
minor surgeries the limit of 24 hrs hospitalization is waived off. For
example, Apollo DKV Easy Health policy covers medical expenses for 140
day care procedures which do not require 24 hours hospitalisation due
to technological advancements.
A few such treatments are listed below:
a. eye surgery
b. dental surgery due to accident
c. dialysis
d. Coronary angioplasty and angiography
e. Kidney stone removal
f. Treatment of fractures / dislocations excluding hairline fractures
g. Surgery of Appendix, Gall Bladder, Pancreas, Bile Duct, Hernia,
Prostate and ENT
h. Radiotherapy.
4. Pre & Post Hospitalisation cover
Besides hospitalization expenses, most healthcare policies also allow
you to claim relevant medical expenses incurred during 30 days prior
to hospitalization and 60 days after hospitalization.A few healthcare
policies provide wider coverage like Chola Health Insurance Plan
covers 60 days prior to hospitalization and 90 days after
hospitalization if you inform them well in advance.In star Health
Insurance for post hospitalisation, a lumpsum calculated at 7% of the
hospitalisation (excluding room charges)subject to a maximum of Rs.
5000/ is payable.
5. Domiciliary Hospitalization
Domiciliary hospitalization means the medical treatment is done at
home for a period exceeding 3 days for any ailment or injury, which
otherwise would require hospitalisation, due to either non-
availability of accommodation in the hospital / Nursing Home or if the
condition of the patient is such that he cannot be moved to a
hospital.
Only a very few insurance companies allow domiciliary
hospitalization. For instance, while Reliance Health Care Policy and
Apollo DKV Easy Health policy allows domiciliary hospitalisation,
Bajaj Allianz, ICICI Lombard and National Insurance Company exclude it
from the coverage.
Exclusions
It is always better to know beforehand various exclusions and
limitations about the mediclaim policies so that you’re aware of the
exact scope of the policy coverage to avoid the disappointment later
at the time of making a claim. Some of the common exclusions (although
vary from policy to policy) are as follows:
6. Waiting Period
Almost all Healthcare or Mediclaim policies carry a waiting period
usually of 30 days. Put simply, you can’t make any claim for any
diseases contracted within 30 days of buying the health / mediclaim
insurance. However, accidental injuries are covered from day one i.e.,
waiting period is not applicable in case of hospitalization / surgery
due to accident.
7. Pre-existing diseases
A fresh mediclaim policy doesn’t cover pre-existing diseases. They get
covered only if you don’t make any claim for 4 or 5 consecutive years.
In other words, pre-existing diseases gets covered usually after 4 or
5 continuous claim free years.
For example, while National Mediclaim policy, United India Mediclaim,
Star Health Insurance, Apollo DKV Insure Health and Bajaj Allianz
Health Guard cover pre-existing diseases after 4 claim free years,
Royal Sundaram Alliance Health Shield Standard, ICICI Lombard
Comprehensive Health and Bajaj Allianz Insta Insure cover them after 5
claim free years.
However, there are exceptions also, for example Reliance Individual
Mediclaim (silver plan) and ICICI Lombard Health Advantage Plus covers
pre-existing diseases after second year (i.e., from third year
onwards), and Apollo DKV Easy Health covers them after a period of 3
years.
8. Temporary Exclusions
There are certain diseases which are covered after 1 or 2 years.
For example, Medi-Classic Individual Policy from Star Health and
Allied Insurance Company Limited excludes Hysterectomy, replacement
surgery for knee and / or joint ( other than caused by accident),
prolapse of interverbial disc(other than caused by accident), varicose
veins and varicose ulcers. during first two years. Benign prostate
hypertrophy,Hydrocele, Hernia, Piles,fistula in anus, Sinusitis, Gall
stone and Renal Stone removal / treatment etc during the first year
In contrast, Mediclaim Insurance Policy from NIC excludes (in addition
to other temporary exclusions) all the above ailments (except Joint
replacement surgery) during first two years. Besides, it excludes
Joint replacement due to degenerative conditions, age related
osteoarthritis and osteoporosis during first 4 years of policy.
Similarly ICICI Lombard Health Advantage Plus also excludes (in
addition to other temporary exclusions) all the above mentioned
medical conditions or treatments during first two years.
9. Permanent Exclusions
There is a long list of ailments that are excluded from the purview of
mediclaim policies. Here’s a list of few such general ailments and
medical treatments which are not covered:
a. Dental treatment except arising out of accidents.
b. Pregnancy and child births
c. OPD expenses
d. Naturopathy, alternative medicine/treatments including acupressure
and magneto-therapy etc.
e. Sexually transmitted diseases (STD) and AIDS
f. All psychiatric disorders
g. Circumcision, cosmetic surgery, plastic surgery unless required to
This is only an indicative list. Further, there are many exceptions to
the above list, for example, Medi-Classic Individual Policy from Star
Health and Allied Insurance Company Limited allows for treatment under
alternative system of medicines (except Naturopathy treatment) but is
limited to 25% of the sum Insured, subject to a maximum of Rs 25,000
in the entire policy period.
Similarly, ICICI Lombard Health Advantage Plus ,Apollo Dkv, Star
Health Gain also allows OPD expenses, dental treatment etc (but
subject to limits specified).
10. Overseas Medical treatment
Medical treatment abroad is also not covered under the health /
mediclaim policies
We have to take overseas Travel mediclaim policies before departure.
devarajan shanmugam
Jul 9, 2009, 11:41:39 PM7/9/09
to MediclaimPolicyforAll
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