Difference Between Mediclaim And Health Insurance

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In your quest to find the best health insurance policy, you may have read a number of articles on insurance on the web. While doing so, you would have come across different terms such as top-ups, family floaters, mediclaims, etc.

In this article - we’ll talk about mediclaims. What is a mediclaim? Is it different from health insurance?

Well, Mediclaims And Health Insurance Policies Are Basically The Same Thing!

Here's why they’re named differently -

  • Government/PSU insurers first came up with ‘mediclaims’ in 1986 when they launched their first plans in India, such as Oriental Mediclaim Policy, New India Assurance Mediclaim, etc.
  • A number of limitations existed in early-day Mediclaim policies, including room rent limitations, disease-based caps, and copays. This resulted in a less favourable impression of Health Insurance/Mediclaim in the minds of consumers.
  • Insurers therefore consciously dropped the name Mediclaim and began referring to all future releases & regulations as 'Health Insurance'.
  • These health insurance policies have gotten rid of some of the limitations mentioned above. With time, insurers began removing the limitations that existed in the so-called Mediclaim products and replacing them with more inclusive health insurance products. The health insurance we have today is the latest and most advanced.

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Health Insurance And Mediclaim Are The Same, But What Do They Cover?

Some people believe that Mediclaim policies cover only hospitalisation expenses and not Pre and Post-hospitalization expenses, while health insurance policies cover the entire gamut of medical expenses.

This is not the case. No matter the type of policy you have - be it a Mediclaim or a health insurance policy - it covers only specific expenses -

  • Pre-Hospitalisation Costs

You may have to pay for tests or consultations before being treated or admitted to the hospital, which is called a pre-hospitalization cost. A health insurance policy covers these costs. Pre-hospitalization costs are generally covered for 30 to 90 days under most health insurance plans.

Costs associated with Pre-Hospitalization include -

  1. Blood tests
  2. X-rays
  3. OPD consultations fees
  4. Diagnostic tests like ECG, EEG
  5. Urine test, etc.

For example, Asha has health insurance with a sum insured of Rs 10 lakhs. She experienced severe stomach pain for three days and she consulted a doctor.He recommended an abdominal CT scan and told her she would need to be hospitalised for 2-3 days. Her health insurance policy will cover the CT scan, any other tests, room rent, medicines, consultation fees, etc. - provided there is an active line of treatment done while she was hospitalised.

  • Hospitalisation Costs

Admission to a hospital comes with certain hospitalisation expenses such as room rent, surgery cost etc. Health insurance covers these hospitalisation costs. Please note that hospitalisation for at least 24 hours is required in order to qualify for a claim. There is one notable exception to this rule. It will be addressed later.

Health insurance covers the following hospitalisation expenses:

  1. Medical treatment expense
  2. Doctor consultation fees
  3. Oxygen supply
  4. Blood supply
  5. ICU charges
  6. Surgery cost
  7. Room rent
  8. Medicine costs, and so on.
  • Post-Hospitalisation Costs

Expenses incurred after being discharged from the hospital are also covered under health insurance. Post-hospitalization costs are usually covered for 60 to 180 days under these plans.

Expenses covered by this category include

  1. Costs associated with regular check-ups or follow-up visits to the doctor
  2. Diagnostic tests such as colonoscopies, ECGs, etc.
  3. Costs associated with rehabilitation
  4. Physiotherapy sessions costs, and so on.

For example, Vikram has health insurance with a sum insured of Rs 5 lakhs. In this case, he underwent appendicitis surgery, which cost approximately Rs 1 lakh. Doctors scheduled biweekly medical appointments to monitor the surgical wound. The surgery costs and follow-up consultation charges will be covered by his health insurance.

  • Cost Of Daycare Procedures

There are some surgeries or treatments that don't require overnight hospital stays, i.e., the duration of stay may not exceed 24 hours. Health insurance policies cover these as well.

  1. The covered treatments include :
  2. Chemotherapy
  3. Cataract
  4. Gallbladder removal
  5. Hernia
  6. Dialysis, etc.
  • Costs Of Hospitalisation At Home

  1. If there is an unavailability of hospital beds or if you are not in a state to be moved to the hospital because of an illness or injury, you can receive treatment at home. This is known as Domiciliary Hospitalisation. Most Insurance plans usually cover all costs associated with domiciliary hospitalisation.
  2. Domiciliary treatments are overseen by a Registered physician and monitored by nurses/paramedics.
  • Costs Of The Organ Donor

The hospitalisation and surgical costs incurred by an organ donor during an organ transplant are covered by health insurance policies. In the absence of such coverage, the Insured/Organ Recipient is responsible for the expenses incurred by the organ donor during the period of hospital stay.

  • Optional Covers/Add-Ons

Add-ons are optional benefits that can be purchased with your existing health insurance policy at a certain extra cost.

Some of the add-ons available with Health Insurance/Mediclaim -

  1. Additional No Claim Bonus
  2. Critical Illness Add-on

A waiver on the exclusion of non-medical expenses including consumables, waiver of copay, etc.

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Wrapping Up!

Health insurance and Mediclaim are the same. In addition to hospitalisation, pre-hospitalization, and post-hospitalisation costs, health insurance policy or mediclaim covers expenses during hospitalisation at home and daycare procedures. Make sure you go through your policy documents to know the scope of coverage.