How is a Health Insurance different from a Mediclaim Policy?



Difference between Health Insurance and Mediclaim Policy

Even before one can zero-down on a Health Insurance provider that they feel is best for them, it is suggested that an individual first understands the difference between a Health Insurance Policy & a Mediclaim Policy since they are very different in terms of the coverage they offer.

Where a Mediclaim Policy offers coverage only for Hospitalization – whether in-patient or domiciliary; a Health Insurance is more comprehensive & extends coverage beyond basic hospitalization to include coverage for Ambulance, Day Care Treatments, OPD Expenses, Critical Illnesses, Pre & Post-Hospitalization Expenses & much more.

Hospitalization coverage in case of Mediclaim policy is limited to some specific pre-defined illnesses & does not cover major critical illnesses such as cancer, major heart surgeries, liver transplant etc. Although a Mediclaim policy just like Health Insurance Policies offer family floater plans which means one could cover multiple family members in a single policy. This means parents, spouse and children, all could be covered in a single policy. Another type of Mediclaim policy is Group Mediclaim wherein coverage is extended to a Group of people – for example employees of an organization. Furthermore, such plans also offer Tax Rebate on premium paid under section 80D of Income Tax Act.

Despite the aforementioned benefits, most experts recommend having a Health Insurance plan instead. One of key reasons is that a Health Insurance plan is designed keeping all healthcare requirements of an individual in mind. It accommodates coverage from the very start of any health issue i.e. OPD expenses such as doctor consultations, diagnostic tests & pharmacy which one might incur before they get hospitalized. These are often called Pre-Hospitalization Expenses. Moving on a Health Insurance also covers expenses towards ambulance and treatments for which one does not need to be hospitalized for more than 24 hours. These are commonly known as day-care treatments.

Furthermore these plans cover non-allopathic treatments such as Ayurveda, Unani, Siddha and Homeopathy thus making them very relevant for individuals who believe in alternative format of medicine.

It is also to be noted that Health Insurance plans offer Global Coverage for planned hospitalization which means an individual can choose to get cashless hospitalization for specified illnesses from a medical facility abroad. Another reason why Health Insurance plans takes an edge over Mediclaim policies is the fact that they offer a host of add-on covers which can empowers an individual to enhance/upgrade their coverage by paying a very small amount.

Insurance suppositions can be different from one another. An insurance plan that works for one family might not work for another. For this very purpose, all health insurance companies provide a wide range of plans that can be tailored to suit different people with different medical backgrounds. 

Religare Health Insurance resolves to offer a solution for customers of all walks of life. Their comprehensive Health Insurance – ‘Care’ offers the aforementioned benefits and in addition comes with features like Automatic Recharge of Sum Insured, Annual Health Check-up for all Insured Members, No-Claim Bonus & Air Ambulance Cover. All of this with a service commitment of just 2 hours for a cashless claim approval.

Cashless Mediclaim Policy for Family in India

Health Insurance offers to its customers two ways in which they can claim – reimbursement & cashless. Every health insurer allows its customers to avail cashless treatment across any hospital empaneled in their network. Simply put, a cashless Mediclaim policy is one where the health insurance provider company deals with the expenses directly with the healthcare institution. This is done, to minimise the direct financial load on that particular individual at the time of hospitalisation. For the customer this is highly convenient. There few things to be kept in mind to make one’s experience hassle-free is to intimate the insurer post admission within the time-period specified by the insurer. In most cases this is 48 hours. Apart from this one should read all key policy terms & conditions and keep their health card handy for this is needed to be presented the hospital.

However in case an individual at the time of emergency wishes to go-ahead with their treatment in a hospital of their choice and which is not in the insurance company’s list – they can still claim. In this case, they will have to bear the hospital expenses from their own pocket & file for reimbursement after getting discharged.

Things That Separate Mediclaim from a Health Insurance

Mediclaim usually provides coverage against hospital bills, treatment expenses that occur during accidents and a list of specific diseases. Typically, there are often three types of exclusions in a Mediclaim insurance plan:

    •    Permanent (diseases that are not covered at all)

    •    Temporary (diseases that are covered after a specific time period is covered)

    •    Limited (diseases covered within the policy with a cap on the payout)

There is a number of other exclusions - temporary or permanent that are not covered by most Mediclaim policies - wars, nuclear weapon strikes, circumcision, non-allopathic treatment, pregnancy and childbirth-related complications, cosmetic surgeries, HIV or AIDS-related diseases, substance abuse, intentional self-injury, vaccination, vitamins, nutritional supplements, cost of spectacles, hearing aids and artificial teeth. Usually, Mediclaim policies cover dental only if it mandates a minimum of 24 hours of hospitalisation. 

These days there are options also to have a Mediclaim policy to suit senior citizens. The age for a senior citizen to apply is between sixty-one to sixty-nine years. The premium for the Mediclaim for senior citizens is usually high. Some insurance companies also offer add-on coverages for alternative medical treatment methods. 

Religare Health Insurance’s plan – ‘Care Freedom’ is best suited for Senior Citizens & comes with no-age restriction for enrolment, which means that even an individual of 100 years can apply. What is truly customer centric about this product is that it can be availed without undergoing any pre-policy medical check-up & it offers a very short wait-period of just 2 years for pre-existing ailments. 

Health Insurance and Mediclaim - The Most Basic Differences

Mediclaim policies are often very restrictive, but can come in handy during emergencies like hospitalization due to accidents. However, since health insurance offers 360-degree coverage, it has many added benefits and features, some of which are listed below.

1. Alternative treatments: As per the guidelines of the Insurance Regulatory Development Authority of India, health plans can cover alternative treatments such as Ayurveda and Homoeopathy (AYUSH). Religare Health Insurance’s plan – ‘Care’ offers coverage for Ayurveda, Unani, Siddha & Homeopathy.

2. Annual Health Check-ups: Health Insurance Company’s endeavor is not just curative care but also preventive care and most insurers these days offer an Annual Health Check-up which every insured member can avail once.

3. No claims bonus: Insurance companies give a cheer to their customer who does not claim in a policy year. They do so by offering them a no-claim bonus. Insurers offer a 10% increase in Sum-Insured for 5 years i.e. a maximum increase of 50% in 5 claim free years.

4. Automatic Recharge of Sum Insured: So that one never runs out of coverage. Insurers reinstate the sum insured amount once it gets exhausted in a policy year. This is at no extra cost and technically the insured gets double sum insured for the same premium. 

5. Daily hospital cash allowance: During hospitalisation, health insurance could also offer additional coverage like food and hospital visits.

6. Organ Transplant: General Health Insurance plans cover surgery costs for organ transplants as an add-on, either in full or in partial amounts.

7. Lifelong renewability: Once enrolled an insured can stay covered for lifetime as long as they timely renew their policy every year. 

8. Maternity expenses: Health insurance policies come with an in-built maternity cover that takes care of both prenatal expenses (check-ups, tests, medication, ambulance services) and postnatal expenses (follow-up visits, necessary after tests). Some policies also extend coverage to insuring new born’s health from birth to ninety days. The waiting period for such policies is nine months.

Mediclaim Policy Comparison: Things You Need To Know

A Mediclaim policy limits itself to just the hospital or nursing home dues. General Health insurance is an all-inclusive insurance policy that can cover much more.

Here are a few main points of comparison between a Mediclaim policy and general health insurance:

1. A Mediclaim covers hospitalisation expenses, accident-related treatments and pre-existing diseases only for a specified time limit whereas a health insurance plan offers all-inclusive coverage against all pre and post hospitalisation charges, ambulance expenses, travel expenses etc. It also offers coverage in case of loss of income due to an accident.

2. Mediclaim policies do not include any other side coverage whereas a general health insurance covers cover critical illnesses, accidents, serious disabilities and maternity related expenses.

The main characteristics of a Mediclaim policy might vary from one insurance provider to the other, whereas the benefits and advantages that can be availed from a general health insurance plan remain the same over most health insurance providers.

The sum assured for a Mediclaim plan is restricted to five lakhs only and the sum assured for a health insurance plan can go unto six crores, per year. 

A Mediclaim policy holder has the right to file claims until the total amount is completely exhausted. In general health insurance, the money has to be paid in a lump sum. Hence these claims can be made only once during the entire policy duration.

It is necessary for the insured person to be actually hospitalised to avail his or her Mediclaim benefits. However, to avail health insurance benefits, it is not necessary for the insured person to be actually hospitalised. Benefits like day care, regular check-ups, pre-natal expenses can be availed.

Points To Keep In Mind While Purchasing Health Insurance

Medical emergencies come unannounced and bring with them a long-list of expenses which owing to lack of adequate planning often leads to financial distress for the patient & their family. Having a comprehensive Health Insurance helps in managing such situations and one must foresee the future cost of their healthcare needs before deciding on the quantum of coverage.

With so many product options in the market, selecting the right cover could be a daunting task. However being apprised of certain key requisites when buying a Health Insurance might make the process a lot simpler – here are four imperatives that one must consider before settling for a plan.

Waiting period

Every health insurance policy has a waiting period, especially for specified list of illness & pre-existing diseases. This basically means that the insured would have to wait for a certain period of time before they can claim for these. This waiting period can range from 1-4 years, depending on the policy & insurer.

Since most major illnesses occur at a progressed age it advisable to get health insured at a young age so that one can avail complete policy benefits when required.

Comprehensiveness of Coverage

Health Insurance plans go beyond covering expenses incurred at the time of hospitalization and even cover other miscellaneous medical expenses such as - pharmacy bills, diagnostic tests & doctor consultations; incurred 30 days before and 60 days post hospitalization.

Furthermore, apart from allopathic treatments there are plans available in the market that offer coverage for non-allopathic treatments such as Ayurveda, Unani, Homeopathy & Siddha. Some insurance products offer you the options of availing treatment overseas and even recharging one’s sum insured amount should the same be exhausted during the policy year.

Another important thing to consider is cashless hospitalisation. Health insurers have a network of hospitals at which they provide cashless treatment. This facility makes one free from the stress of arranging funds at the time of an emergency and even eases the discharge process. It is advisable to opt for an insurance plan that has quality empanelled hospitals within your proximity.

Claims procedure

Your insurance plan should make things easy for you, and should not add on to the stress for you or your family at the time of emergency. The claims process should be simple and quick. Opt for an insurer which is well-reputed for its quick claims settlements for e.g. cashless claim approval TAT could be a good measure of claim settlement efficiency. There are insurers who handle the claim settlement process in-house which has certain obvious merits.

 Applicable Sub-limits

Sub-limits are monetary caps that insurers place on the insurance cover amount. Basically it means that the insurance company will limit its liability, which is the amount to be paid for a medical service, in certain cases by placing sub-limits over specific medical charges. In this case, the insurer will only pay a certain sum for a medical expense and the rest will have to be borne by the individual.


When buying a health insurance policy, compare the sub-limits that different insurers have included in their plans. The less number of sub-limits in a plan, the better it is. However, have a good understanding about the sub-limits which you can afford to have.