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Health Insurance

Health & Personal Accident

Health insurance plans secure the medical and surgical expenses of the insured in the event of an injury/ illness. They may be taken by an individual or a group. It is an essential coverage against rising medical costs and to be able to avail quality healthcare services. Personal Accident Insurance policy on the other hand provides monetary compensation to the policyholder in the event of bodily injuries, disability and even death arising from an accident, violent, visible and external event.


Mediclaim Policy provides cover for healthcare expenses incurred by insured in a hospital due to a medical emergency, such as illness or accidents. This policy provides coverage to individuals and their covered family members against expenses such as hospital room/ICU charges, diagnostic charges, medicine and other medical expenses.


  • Individual health insurance policy means a separate policy for each family member with an individual sum insured. The plan has a fixed sum insured, up to which, the insurer will cover the healthcare costs of the policyholder.
  • Family Floater health insurance is one single policy that takes care of the hospitalization expenses of your entire family. The policy has one single sum insured, which can be utilised by any/all insured persons in any proportion or amount subject to maximum of the policy sum insured.
  • Senior Citizen Health Insurance is offered by different insurance companies in India to financially secure those who are aged 65 years and above. They are designed to cover all kinds of medical expenses that are incurred by the policyholder.

Features & Benefits

The key features and benefits of a mediclaim policy are:

  • Suitable for any person between the age of ninety one days to sixty five years

  • Offers the power to either opt for self or for the entire circle of relatives (spouse, children, parents)

  • Covers pre-existing medical conditions after a waiting period of 2- four years

  • Get higher cover at low-priced premium rates

  • Offers the benefit of a high sum insured of as much as Rs. 50 lakhs or even more

  • Can be ported to another distinctive insurer at the time of renewal

  • Gives you and your family a complete health cover, proving to be an effective protection option

  • Includes cashless hospitalization to ensure that you don't have any out-of-pocket medical expenses

  • Easy online buying method from the comfort of your home

  • Enables you to avail tax deductions on premiums paid underneath Section 80D of the Income Tax Act, 1961

  • Can be renewed annually. Some insurers provide longer duration policies with renewals due each 2 or 3 years


Benefits covered by a mediclaim may vary depending on the insurance company. These are the common benefits covered by mediclaim policies:

  • Hospital expenses: Expenses incurred due to hospitalization like medicines, oxygen, blood, OT charges, medical tests and diagnosis, chemotherapy, radiotherapy, organ transplantation, etc.

  • Hospital accommodation expenses: Expenditures towards ICUs are either addressed through cashless hospitalisation feature or are reimbursed by the company.

  • Day-care hospitalization: Expenditures towards tech-driven medical treatments that do not involve 24-hour hospitalization.

  • Charges for medical experts: The fees for medical professionals involved during hospitalization like doctor, nurse, etc. are also provided by mediclaim policies.

  • Hospital lodging expenses: Expenditures towards ICUs are both addressed via cashless hospitalisation feature or are reimbursed via the insurer

  • Pre and post-hospitalization expenses: Expenses incurred for up to 30-60 days before and till 60-120 days after hospitalization. It may also include medical assistance for emergency services like ambulance, etc.

Exclusions: What is Not Covered

  • War or any act of war, invasion, an act of foreign enemy, warlike operations

  • Biological/Chemical/Radioactive/Nuclear fallout

  • Self-inflicted injuries

  • Maternity and pregnancy treatments

  • Breach of law/criminal activity

  • Participation in military operations

  • Participation in extreme sports

  • Substance Abuse/Alcohol/Narcotics

  • Treatment of Obesity

  • Cosmetic Surgery

  • Dental Treatment


  • Infertility treatments

Factors Determining Premium

  • Age is a major factor that determines the premium, the older you are the premium cost will be higher because you are more prone to illnesses.

  • No of Members Included in the floater policy affect the premium 

  • Previous medical history and lifestyle factors are major factors that determine the premium. If no prior medical history exists, premium will automatically be lower.

  • Claim free years can also be a factor in determining the cost of the premium as it might benefit you with a certain percentage of discount which will reduce your premium.

Claims Process

In mediclaim you can make two types of claims- Cashless and Reimbursement

Cashless Claim

In this type of health insurance claim, the insurer settles all the hospitalization bills with the hospital directly, provided he is hospitalised at a network hospital. The procedure to avail cashless claim for a health insurance policy is:

  • Contact the hospital’s insurance help desk
  • Show the ID card of the insured, provided by the health insurance provider
  • The hospital will verify the insured person’s identity and submit the pre-authorization form to the concerned health insurance provider
  • The insurance provider will review all the submitted documents and process the claim according to the terms and conditions of the health insurance policy.
  • Some of the health insurance providers also assign a field doctor to make the hospitalization process easier for the insured.
  • After the completion of all formalities, the claim is settled as per the terms and conditions of the policy.

Reimbursement Claim

In this type of health insurance claim process, the policyholder pays for the hospitalization expenses upfront and requests for reimbursement by the insurance provider later. This can be availed at network and non-network hospitals. The insured has to submit the following documents to the insurance provider in order to avail the claim:

  • Duly filled and signed Claim form

  • Insurance Card or Policy Copy

  • Medical Certificate signed by the doctor

  • Pathological reports like X-ray reports

  • Hospital discharge card

  • Original Bills and receipts

  • Original Pharmacy bills

  • Investigation report, if any

  • FIR / MLC Copy (in case of an accidental claim)

  • NEFT Details to credit Claim Settlement

  • Duly Filled CKYC Form if Claimed amount is above Rs 1L.

Frequently Asked Questions (FAQs)

Third Party Administrators (TPAs) are IRDA licensed entities who serve as intermediaries between the insurer and the insured to ensure smooth settlement of claims. Find the list of TPAs here.
Any number of claims is allowed during the policy period unless there is a specific cap prescribed in any policy. However, the sum insured is the maximum limit under the policy.
It is a Card that comes along with the health insurance policy which allows you to avail cashless hospitalisation normally issued by your Third Party Administrator.

The following documents are generally required for purchasing a health insurance policy:

  • KYC - Proof of ID and Address
  • Age Proof
  • Medical Check-up/Report if required
  • Passport-sized photograph

The insurer will mention it in their policy buying procedure if any other document is required.

This is the sum insured of the policy you take which should be calculated keeping your existing lifestyle, family members, medical history, income, city of residence and age in mind.

Critical Illness

Critical Illness Insurance is a type of health insurance plan wherein the insured receives a lump sum amount equal to the sum insured on acquiring a serious ailment like cancer, heart attack, stroke etc. The lump sum payment can cover the hospitalisation and treatment expenses, recuperation expense and any other debt as well. The insured receives the entire sum insured irrespective of the hospitalisation costs.

Features and Benefits

The key features of critical illness insurance are:

  • Provides cover ranging from a minimum of Rs. 1 lakh

  • 30 day grace period is applicable

  • Sum assured is paid as lump sum

  • Medical screening is required if the policyholder is above the age of 45 years

  • Day care procedures (less than 24 hours) are covered

  • Pre-existing diseases are not covered

  • Cashless facility is available

The key benefits of critical illness insurance are:

  • Coverage is provided for up to 36 life threatening diseases

  • Convenient, fast, hassle-free claims process

  • The sum assured provided is in the form of lump sum payment which can be used as an income replacement

  • 100% benefit payout upon diagnosis of terminal illness

  • Provides accidental death benefit

  • Protection against disability

  • The premium paid towards a critical health insurance plan is eligible for tax deductions under Section 80D of the Income Tax Act, 1961.


The following are normally covered Critical Illnesses with various Insurance Companies:

  • Heart Attack (Myocardial Infarction)

  • Coronary Artery Bypass Surgery

  • Stroke

  • Cancer

  • Kidney Failure

  • Major Organ Transplantation

  • Multiple Sclerosis

  • Paralysis

SInce the coverage could differ from policy to policy and hence it is crucial to compare the illnesses covered before buying the policy.

Exclusions: What is Not Covered

  • Pre Existing Conditions

  • Illness or Injury diagnosed within the first 90 days of the inception of the Policy

  • War or any act of war, invasion, an act of foreign enemy, warlike operations

  • Biological/Chemical/Radioactive/Nuclear fallout

  • Self-inflicted injuries

  • Aggravated pregnancy or childbirth

  • Breach of law/criminal activity

  • Participation in military operations

  • Participation in extreme sports

  • Substance Abuse/Alcohol/Narcotics

  • Cosmetic Surgery


Factors Determining Premium

  • Age: A person’s age plays an important role in determining the premium amount. Younger you are, the cheaper your policy will be.

  • Health Status: High blood pressure, overweight or other medical conditions that can lead to future health problems will lead to higher premiums.

  • Family History: If any of the family members have a history of serious illness such as heart disease or diabetes then due to heredity you are more likely to get such ailments. In such a situation you may have to pay  higher premiums
  • Coverage Requirements: Opting for more benefits and coverage will require you to pay a higher premium.

Claims Process

The following documents should be submitted by the insured to initiate the claims process:

  • Duly filled and signed claim form

  • Medical Certificate confirming the diagnosis of Critical Illness

  • A medical certificate, investigation test report, etc. from an attending Medical Practitioner authorising that the claim does not relate to any Pre-existing conditions or any Illness or Injury which was diagnosed within the first 90days of the inception of the Policy.

  • Discharge Card/ Death Summary from the hospital, if applicable

  • First Consultation letter and subsequent prescriptions

  • Specific documents listed under the respective critical illness

  • Know your client doc (KYC)

  • In the case critical illness arises due to an accident, FIR copy would be required.

  • Other medical or Pharmacy Bills along with the required prescriptions

Frequently Asked Questions (FAQs)

Under a benefit policy, the policyholder is paid a lump sum amount if the insured event takes place.
Yes, the policyholder can avail upto Rs.15,000 as tax benefit under ‘Section 80D’. In case of senior citizens, you can avail upto Rs.20,000 as tax benefit under 'Section 80D'.
Critical Illness policy covers individuals in the age group of 5 years to 45 years. Children between 5 years to 18 years would be covered only when both the parents are also insured under the policy.
Any ailment, injury or related condition(s) for which the insured person had signs or symptoms and/or was diagnosed and/or received medical advice/treatment within 48 months prior to the first policy with the Insurance Company.

No pre policy medical check up is required for individuals upto 45 years.

Personal Accident

Personal Accident Insurance policy provides monetary compensation to the policyholder in the event of bodily injuries, disability and even death arising from an accident, violent, visible and external event.

Types of Coverage

  • Accidental death
  • Permanent Total disablement (PTD)
  • Permanent Partial Disablement(PPD)
  • Temporary Total Disablement(TTD)

Add on Covers

  • Education Benefit

  • Employment Benefit

  • Ambulance Benefit

  • Cumulative Benefit

  • Compensation for clothing damaged in an accident

  • Expenses for the carriage of the dead body

  • Modification allowance

  • Family transportation


  • Self-injury

  • Suicide

  • Venereal disease

  • Insanity

  • Influence of intoxicating liquor or drugs

  • War and nuclear risks

Claims Process

This policy provides complete cover in the event of death or disablement of the insured due to accidents occurring anywhere in the world. The following documents are required to make a claim:

  • Claim form

  • Death Certificate

  • FIR/MLC/Police Final report/Railway Guard Memo (In case of a Railway accident)

  • Post Mortem Report/Viscera Report/Certificate from treating doctor giving proximate cause of Death.

  • If Medical expenses are to be claimed - Medical bills and cash memos, Doctor’s Prescriptions, and hospital Discharge summary

  • AML Documents (address and id proof) and KYC form

  • ID Proof of the Nominee & Deceased.

Frequently Asked Questions (FAQs)

Personal Accident Insurance is open to everyone from the age of 18 years to 65 years.
Life insurance offers death benefits to your nominee in case you pass away. Health insurance provides compensation towards your hospitalization and other medical expenses. But a Personal Accident Insurance policy, insures you against the financial risk that could arise due to accidental permanent total disability or accidental death of an earning family member. In short, the policy is essential as it strengthens your financial portfolio and secures the future of dependent family members against unforeseen events.
Yes, it does cover accidental death, in which case the sum insured will be paid to the nominee as mentioned in the policy document.
The policy commences within 15 days from the date of receipt of form & premium payment.

Pays 10 % of Sum Insured upto 50,000(for dependent parents), if an accident results in broken bones.

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